Secure Order Form

Choose a Medication

A FedEx Next Day shipping charge of $18 will be added to your order

Patient Information

NOTE: You will be required to sign for delivery.
There will be a $10.00 charge if an address change is necessary after submission and confirmation of your order.

E-mail Address :	eg, name@aol.com
First Name :
Last Name :
Day Time Phone :
Evening Phone :

Credit Card Information

Card Holder's Name :
Credit Card Type :
Credit Card Number :	no dashes or spaces e.g., 4568256901056035
Expiration Date :	mm/yy e.g., 08/04

Billing Address

We cannot ship to P.O. Boxes

Street Address :

Suite / Floor / Apt # :

City :

State :

Zip Code :

	Check this box if your shipping address is the same as your billing address

Shipping Address

We cannot ship to P.O. Boxes

Street Address :

Suite / Floor / Apt # :

City :

State :

Zip Code :

Medical Questionnaire

Date of Birth :	e.g., 06/14/65
Sex :

Do you have high blood pressure? (greater than 140/90)
I agree not to take any over-the-counter medicines without approval from my pharmacist
I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately
I agree to not take this medication if I am pregnant, breast feeding, or trying to get pregnant

Please list any current medical conditions: (If none type 'None')

Please list all medications you are currently taking: (If none type 'None')

Please list all medications that you plan to take while on this program: (If none type 'None')

Please list all allergies (including medications): (If none type 'None')

Please list any surgeries: (If none type 'None')

Is there anything else in your medical history you deem relevant? (If none type 'None')

Weight Loss Specific Questions

Please enter your height in feet and inches:	feet	inches
Your Weight in pounds:	pounds
	Your BMI is
*You must have a BMI of 27.0 or greater* to receive prescription weight loss medications.**

Patient Responsibility Statement and Informed Consent

Important Click each link to view the documents in a pop-up window. To continue, you must agree with the following.
Click Here to Read The Patient Responsibility Statement I Have Read, Understand and Agree
Click Here to Read The Informed Consent I Have Read, Understand and Agree
I would like to receive information from you about health tips, new site features and product promotions.
Click the "Submit" button only once. Multiple clicks will result in multiple charges on your credit card. Please review form for accuracy before submitting Credit Card Fraud is a criminal offense in any country. We use the most extensive service to validate your credit card in order to further protect you. Federal Law prohibits the return of any prescription medication.