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	Xenical^® Prescription Consultation

Review and update your account information.

Use the Account Manager to view your current records. If any personal or medical information has changed since your last visit, please update and re-submit your records before continuing. Be sure to check that your general information, medical history, current medications, and allergy charts are all up-to-date.

Complete the following medical review.

The questions below are specific to receiving a Xenical^® prescription. This information will be evaluated in conjunction with your general medical records from "Step 1". Please answer all questions truthfully and completely, to the best of your knowledge.

Where do you want to purchase this medication?

Store #

What dosage and/or treatment duration are you requesting?

What is your current weight?

lbs.

What is your height?

Have you had a complete physical exam with blood tests within the last year?

Yes No

How is your blood pressure?

Have you taken this medication before?

Yes No

If yes, did you have any side effects when you last took this product?

Do you have any questions or concerns about this product and your health?

At what age did you start gaining weight?

Years old

What weight loss treatments have you had in the past 12 months?

Are any other immediate family members overweight?

Father	Children	Father's Parents
Mother	Sibilings	Mother's Parents
None

Do you currently have any of the following conditions?

Yes No		Gall Stones
Yes No		Bile Stasis
Yes No		Malabsorption syndromes
Yes No		Allergies to any component of Xenical
Yes No		Are you pregnant?
Yes No		Are you a nursing mother?
Yes No		Are you Anorexic?
Yes No		Are you Bulimic?
Yes No		Are you taking any immunosuppresion drugs, such as cyclosporines?
Yes No		Do you suffer from obesity?
Yes No		Is your obesity due to an organic cause, such as hypothyroidism?

Verify your order.

You certify that all account information is current, accurate, and complete?

Yes No

You are requesting the prescription medication(s) solely for your own personal therapeutic and medical needs, and will not distribute any of the medication to others?

Yes No

You will promptly contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication?

Yes No

You realize there are risks as well as benefits to any medication, even non-prescription drugs. You have been informed of the possible effects, risks, and benefits of this medication?

Yes No

You understand the side-effects of these pills?

Yes No

You understand that you can not have a Xenical^� prescription from more than one physician?

Yes No

You understand that you are ordering a prescription consultation and the fee charged for the consultation is non-refundable and does not include the cost of any medication?

Yes No

You understand that Morris Medical Online Services, Inc. does not guarantee that you will receive a prescription for any medication.

Yes No

You certify that I have and will answer all the questions truthfully?

Yes No

I have answered all questions truthfully,
I have read and agree to the Waiver of Liability
I am legally entitled to receive Xenical^�

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