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Xenical Slimming Pill Order Form

Xenical represent the only prescription fat blocker. Xenical is a prescription fat blocker that blocks one third of of the calories from fat from being utilized.

This is very significant especially when one notes that each gram of fat consists of nine calories, as compared, to one gram of protein or carbohydrates which account for only four calories.

This fat blocking mode enables you to lose weight fast while still enjoying some of the foods in your diet that you like to eat.

Xenical Slimming Pill, Fast Facts:

Fat Blocker - Xenical is the only prescription "Fat Blocker" that prevents one third of the fat calories in your diet from being absorbed and thus converted into fat.

Doctor Recommended - more physicians recommend Xenical than any other weight loss pill. Xenical represents one of the safest prescription weight loss pills on the market today.

Clinical Studies - have proven that if you include Xenical in your healthy diet plan you will lose up to three times more weight than if you were to try dieting without Xenical.

Better Overall Health - Xenical also improves some obesity-related disease risk factors including high cholesterol, high blood pressure and diabetes.

Why try dieting without Xenical? Xenical promotes fast weight loss while blocking 1/3 of the calories consumed in your diet from fats. Order Xenical online now, simply complete the following fast and easy Xenical order form:

Buy Xenical Slimming Pills Securely Online

Welcome to the secure area, as designated by the https://www, in your browser all information provided during the order process is routed behind a secure "firewall". The Information is encrypted at your browser and sent via the Hyper Text Transport Protocol to ensure security. Please note: when you place your order on the secure pages the website address changes from the normal http://www protocol to the https://www signifying that all information provided on the page is protected by the Secure Sockets Layer (SSL). (see illustration below)

Please take a few minutes to complete the fast and easy Xenical medical consultation form so we can safely fill your prescription Xenical order, (all Xenical orders are shipped discreetly with no hint of the contents). You are simply requested to complete a medical questionnaire that addresses your medical history. This information is required by a licensed physician to determine whether the desired medicine is appropriate for your current condition.

Important!

I hereby certify that I am at least eighteen years of age and will carefully read and truthfully answer all of the following questions:

Shipping Address:
First Name:	(required)
Middle Initial:
Last Name:	(required)
Email:	(required)
Confirm Email:	(required)
Address 1:	(required)
Address 2:	(i.e. apt, suite no.)
Town/City:	(required)
Providence/State:	(optional)
Postal / Zip Code:	(required)
Country:	(required)
Phone:	(required for courier purposes only)

Billing Information:
Payment Type:	Credit Card Money Order or Western Union. When paying by money order, the credit card information is not required. The customer service associates will email you with further instructions concerning payment.
Card Holder:	(required for Credit Card Payment Only)
Credit Card Type:	(required for Credit Card Payment Only)
Credit Card No.:	(required for Credit Card Payment Only)
Expiration Date:	(required for Credit Card Payment Only) *Example: 07/08*
CVV2: (Card Verification Value) 0000000000000000	(required for Credit Card Payment Only) For your safety and security, individuals are now required to enter their credit card";s verification number (CVV2 code). The verification number is a 3-digit number printed on the back of most credit cards, (the number appears after and to the right of your card number), please refer to the example. If using an American Express card the CVV2 code is a 4-digit number printed on the front of your card, please refer to the example. Please note: By providing the CVV2 code this helps to insure that the credit card is in the possession of the user helping to decrease fraudulent charges.

Billing Address: The next section addresses the actual billing address where the credit card statement is mailed each month. Please enter the exact address of where the credit card statement is sent each month for payment. This address will be verified with the issuing credit card company prior to charging the credit card. The billing address must exactly match the address on file where the credit card statement is mailed each month, or the charges will not be approved. This represents just another security measure taken by us to prevent fraudulent charges.
Country:	(required for Credit Card Payment Only)
Address 1:	(required for Credit Card Payment Only)
Address 2:	(i.e. apt, suite no.)
Town/City:	(required for Credit Card Payment Only)
Providence/State:	(optional)
Postal / Zip Code:	(required for Credit Card Payment Only)

Medical History (Information provided below is protected by patient/physician privacy laws.
This and all the other information you have entered is encrypted and safe during
transmission over the Internet).

Required Personal Information:
Very important: Our doctors will only precsribe Xenical to those individuals that are over weight with a BMI score greater than 28. (BMI or Body Mass Index is a measure of body fat based on height and weight that applies to both men and women). As a baseline a women that weighs 78 kilograms with a height of 1.67 metres has a BMI score equal to 28 (which indicates she is overweight and would benefit from Xenical.)
Weight:	2.2lb = 1kg (required)
Date of Birth:	(required) *Example: 07/02/79*
Sex:	(required)

Medical History:Please read the following list of medical conditions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
Do you or any of your immediate family have a history of the following medical conditions?
Blood disorders e.g. anemia, hemophilia, hemochromatosis, phlebitis, sickle cell anemia, thalassemia, thrombosis, hypercholesterolemia, etc.
Cancer e.g. brain, breast, bladder, colorectal, endometrial, leukemia, lung, lymphoma, multiple myeloma, ovarian, prostate, skin, testicular, etc.
Cardiovascular disease e.g. angina, arrhythmia, atrial fibrillation, claudication, congestive heart failure, valve disorder, heart attacks, high blood pressure, strokes, etc.
Endocrine disorder e.g. diabetes, goiter, hyperthyroidism, hypothyroidism, pheochromocytoma, thyroiditis, etc.
Eye disorders e.g. cataracts, glaucoma, retinal complications, etc.
Gastrointestinal disorder e.g. acid reflux, hiatal hernia, irritable bowel syndrome (Crohn";s disease, ulcerative colitis), polyps, rectal bleeding, ulcers, etc.
Genitourinary disorder e.g. benign prostatic hyperplasia, cysts, endometriosis, pelvic inflammatory disease, etc.
Immune disorders e.g. Hashimoto";s disease, eczema, HIV, Graves disease, Sjogrens syndrome, sarcoidosis, sclerodoma, etc.
Kidney (urinary tract) disorder e.g. bladder disorders, cystic disease, glomerular disease, nephrotic syndrome, renal failure, urinary tract complications, etc.
Liver disorder e.g. cirrhosis, Gilbert";s syndrome, hepatitis, hemochromatosis, Wilson";s disease, etc.
Musculoskeletal e.g. arthritis, back/spine complications, fibromyalgia, gout, lyme disease, muscular dystrophy, myasthenia gravis, osteomalacia, osteoporosis, rickets, spinal cord injury, etc.
Neurological disorder e.g. Alzheimer";s disease, epilepsy, head injuries, headaches, Huntington";s disease, multiple sclerosis, seizure, etc.
Psychological disorder e.g. anxiety, attention deficit disorder, bipolar disorder, depression, obsessive compulsive disorder, panic disorder, post traumatic stress disorder, etc.
Respiratory disorder e.g. allergic rhinitis, asthma, chronic bronchitis, emphysema, tuberculosis etc.
Other e.g. acne, chemical dependency, menopause, nutritional disorder, obesity, pregnant/nursing, significant trauma, etc.
Do you have a history of any of the medical conditions previously mentioned including Blood disorders, Cancer, Cardiovascular disease, Endocrine disorder, Eye disorders, Gastrointestinal disorder, Genitourinary disorder Immune disorders, Kidney (urinary tract) disorder, Liver disorder Musculoskeletal, Neurological disorder, Psychological disorder, Respiratory disorder, Other conditions (not mentioned)? If yes, please explain. For example, duration of illness, any surgery or treatment (ten year history of hypertension (high blood pressure), Atenolol 50mg one per day - well controlled with medications, Blood pressure 132/84):	Yes No
	0000000

Additional Medical: Please read the following list of medical questions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
Currently, are you taking any medications (this includes over-the-counter or nonprescription medication, herbal supplements, sports supplements, etc.) If yes, please explain(medication, supplement including dosage):	Yes No
Are you allergic to any medications, supplements or food products? If yes, please explain (medication, supplement, and the allergic reaction experienced):	Yes No
Do you consume more than two servings of alcohol per day or use tobacco products? If yes, please quantify type of product and usage:	Yes No
Do you currently follow a routine exercise program? If yes, please quantify type and amount of exercise:	Yes No
	0000000

Xenical Specific Questions: Please read the following list of medical questions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
Currently, are you following any type of diet program or have you been on any diets in the past? If yes, please explain:	Yes No
Do you have a history of any eating disorders e.g. Anorexia, Bulimia, etc.? If yes, please explain.	Yes No
Do you have any history of inflammatory bowel disease e.g. Crohn";s disease, ulcerative colitis, etc. or complications with the biliary tract including the gall bladder or any other medical conditions? If yes, please explain.	Yes No
Do you have an organic causes of obesity including hypothyroidism? If yes, please explain:	Yes No
Are you taking any medications, dietary supplements, laxatives or any types of steroids? If yes, please explain:	Yes No
Are you pregnant, breast-feeding or planning to conceive? If yes, please explain.	Yes No
Are you taking cyclosporine?	Yes No
	0000000

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Buy 84 or more Xenical, with the discount is like getting a free Xenical slimming pill for every five Xenical you purchase.

28 - Xenical 120 mg, FREE Consultation + FREE Shipping =	£69.99
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Special Instructions :

Finally, please list any "special instructions" associated with your order.

Please Note:
Our merchant account (the service that charges your credit card for Visa, MasterCard, etc.) mandates that some of our orders be processed in U.S. currency. Therefore, occasionally our prices may be converted from Pounds to U.S. currency. This conversion in currency will be reflected on your credit card statement.

All currency conversions are done on a daily basis reflected by the most current conversion rate as posted by the credit card companies i.e. Visa, MasterCard, etc.

Avoid Delays:
To avoid delays in processing and/or delivery time, please be sure that all of the above questions that are marked as (required) have been properly filled out. Also check to see if you properly selected the quantity you wish to receive.

Next, simply click on the following submit button
and we will promptly process your Xenical order:

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