123 Diet Pills 4 Weight Loss Order Form

Choose a Medication

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

We cannot ship to P.O. Boxes

Street Address :

Suite / Floor / Apt # :

City :

State :

*You must select a state for your order to be processed

Zip Code :

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 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')

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.

Important Click the links to read in a pop-up window. To continue, you must agree with the following:
I Have Read, Understand and Agree to the Patient Responsibility Statement
I Have Read, Understand and Agree to the Informed Consent
I 'd like to receive promotional e-mail from you with information about health and special offers.
Please review the order form for accuracy before submitting 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.