Xenical Consultation Form

Please take the necessary time to carefully and truthfully complete all applicable questions on the form.  Incomplete forms will not be submitted to our physicians for a consultation, as failure to provide the medical information required to render a professional opinion is prima facie grounds to deny a prescription. If you want to ask us any questions before submitting your form, see our Frequently Asked Questions or e-mail us at inquiries@net-dr.com.

 
Viagra
Personal Information
  Name (First and Last)
required
Address
No Post Office Box
City
required
State
required
Zip Code
required
Country
required
Phone (Required)
required
E-mail Address
(required for confirmation)
Viagra
Current Information
Age
required
Height
  required
Weight
lbs. required
Date Of Birth
(MM/DD/YY)
required
Sex
Male     Female
Viagra
Credit Card Information
Credit Card
required
Name Of Credit Card Holder
required
Credit Card Number
required ; NO DASHES!
Credit Card CVV
required What is CVV? Click Here
Expiration
required
Billing Address
required
City, State, Zip
required
Viagra
 Quantity of Xenical
Multivitamin
Please include a multivitamin supplement ($10 for 100 tablets, includes shipping worldwide)
Quantity
(if approved)
Shipping Method
 
Charge Approval
If I am approved for Xenical, please bill my prescription on my credit card and send me my tablets immediately.
Have You
Been Diagnosed With:
yes   no      atherosclerosis      
yes   no     heart attack                        
yes   no      Crohn's Disease     
yes   no     endocrine disorders           
yes   no      diabetes                    
yes   no     stroke                                 
yes   no      gallstones                    
yes   no     kidney disease/renal          
yes   no      vitamin deficiency    
yes   no     spinal cord injury               
yes   no      cirrhosis of the liver     
yes   no     thyroid disease                  
yes  no     head injury           
yes  no    liver disease                   
yes  no     hepatitis                yes  no    any bowel disorder        
Medical History
Do you suffer from hypertension ?   yes   no  

If yes, what is your usual blood pressure?

Do you have elevated cholesterol or blood lipids?    yes   no

Do you have chronic malabsorption syndrome?       yes   no

Are you taking any of the following drugs?  
insulin        yes   no
glyburide  yes   no
beta-carotene  yes   no
vitamin D     
yes   no
vitamin E  yes   no
multivitamins yes   no
nifedipine 
yes   no

What is your BMI [ Body Mass Index ] ?     [ mandatory ]  If you do not know please click here.

Please list all known allergies:

Are you being treated for other medical conditions at this time?  no   yes (please specify)

What is your past surgical history?

Do any diseases/disorders run in your family?   no   yes (please specify)

Describe your alcoholic beverage consumption: 

Have you ever been treated for substance abuse?   no  yes

If you answered "yes", please describe:

Do you smoke? no  yes  packs per day 

Do you consider anything else in your medical history to be relevant? 
no   yes (please specify)

Do you suffer from depression?  no   yes
(please specify frequency and severity)

Do you have a pacemaker? no    yes
Do you or have you suffered from chest pains? no    yes
Do you suffer from shortness of breath?    no    yes
Do you exercise regularly?         no    yes

                               

If you answered "yes", please describe the nature/duration of your exercise:

Are your natural mother and father alive? no    yes

If you answered "no", please provide any health reasons that contributed to the death of your mother/father:
By submitting this form, I certify that:
 xczxc
I have read and agree to the Net Doctor Group's waiver of liability.
True   False
I am permitted to receive the medication I requested in the state/region/country indicated as the shipping address:
True   False
I have provided truthful information to the best of my knowledge to Net Doctor Group.
True   False
 Submit
Note to US patients: In many cases, a Net Doctor physician shall prefer to speak on the telephone briefly with patients prior to reaching a final decision. Please provide a telephone number (if different than above) where you may be reached and a convenient time in the 24 hours following the submission of your form. If you are not available at the time that the physician phones you, no message will be left, and if someone other than the patient answers the phone no details about the nature of the call or the caller will be disclosed. The physician will try to phone you on the following day at the same time, and if you still cannot be reached, we will contact you via e-mail.

Phone number ( if different from the above ) :

Convenient time to call:

Where did you find us?

By submitting this form you are agreeing to pay a $50 consultation fee. If you are not approved for a prescription, you will not be charged.

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