Choose a Medication

Please Choose A Medication 30 x Adipex 37.5mg $ 60 x Adipex 37.5mg $ 90 x Adipex 37.5mg $ 30 x Bontril 105mg $ 60 x Bontril 105mg $ 90 x Bontril 105mg $ 30 x Didrex 50mg $ 60 x Didrex 50mg $ 90 x Didrex 50mg $ 30 x Ionamin 30mg $ 60 x Ionamin 30mg $ 90 x Ionamin 30mg $ 30 x Meridia 10mg $ 90 x Meridia 10mg $ 30 x Meridia 15mg $ 90 x Meridia 15mg $ 60 x Phentermine 15mg $ 180 x Phentermine 15mg $ 30 x Phentermine 30mg $ 60 x Phentermine 30mg $ 90 x Phentermine 30mg $ 30 x Phentermine 37.5mg $ 60 x Phentermine 37.5mg $ 90 x Phentermine 37.5mg $ 30 x Phentermine (yellow) 30mg $ 60 x Phentermine (yellow) 30mg $ 90 x Phentermine (yellow) 30mg $ 30 x Tenuate 75mg $ 60 x Tenuate 75mg $ 90 x Tenuate 75mg $ 90 x Xenical 120mg $ 180 x Xenical 120mg $ 270 x Xenical 120mg $

About You

E-mail Address : 

eg, name@msn.com

First Name : 

Last Name : 

Day Time Tel : 

Evening Tel : 

Payment Information

Card Holder's Name : 

Credit Card Type : 

Credit Card Number : 

Card Verification Number

Expiration Date : 

mm/yy  e.g., 11/05

Your Billing Address

* This must match the billing address for your credit card

Street Address : 

Suite / Floor / Apt # : 

City : 

State : 

Zip Code : 

Your Shipping Address

Street Address : 

Suite / Floor / Apt # : 

City : 

State : 

Zip Code : 

Medical Consultation

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 it is over 140/90 (top number is greater than 140 or the bottom 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 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 questions

Your height

Your Weight

*

*You must have a BMI of 27.0 or greater to receive prescription weight loss medications.

Terms & Agreement

Important Click the links to read in a pop-up window. To continue, you must agree with the following:

Sumit your Order

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

Note: Your signature is needed upon delivery.
There is a $10.00 charge if you request an address change after submission and confirmation of your order.

Click the Submit Order button only once
Multiple clicks will result in multiple charges on your credit card.

Your Credit Card will be billed discreetly
Credit Card Fraud is a criminal offense in any country. We use the most extensive service to validate your cc to protect you.
Federal Law prohibits the return of any prescription medication.