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Please fill in all sections marked with (*).
 

 

Personal Details
Full Name *
Delivery Address *
Date of Birth (dd/mm/year) *
Gender * Male Female
Your height * (Metres or Ft)
Your weight * (Kg or Lbs)
   

Medical questions for XENICAL
Are you pregnant? * Yes No
Are you breast feeding? * Yes No
Do you suffer from Jaundice? * Yes No
Are you on any other Medication? * Yes No
Please list medications here if the answer is YES:
Have you or do you sufferer from anorexia or bulimia ? * Yes No
Have you ordered from Love Pharmacy before? Yes No


Your XENICAL order
Please supply me with the following XENICAL prescription: *
Please note that it is prohibited to accept returns of prescription medication. We therefore cannot accept returns or refunds.


Agreement
By submitting this application form: AGREE
I certify that I am 18+ years of age
I take full responsibility of informing my Doctor of this medication.
I have read and understand the potential side-effects of Xenical.
I do not have a current prescription for Xenical from another source.
I certify that I am allowed by law to use the credit card used to place this order.
I accept full responsibility for my use of the supplied drugs.
I certify that I have answered all the questions truthfully.


Terms and Waiver of Liability
Do you agree to our Terms and Waiver of Liability? *
Please read our Waiver of Liability. conditions. 		I agree


Please enter your payment information below



Payment information
Name on card *
Email Address *
Card Holder Address*
(if different to Delivery Address)

Telephone *
Card Number *
(numbers only, no dashes or spaces)
Expiry Date *  
Valid From:
Issue No: if using Switch or Solo
CVV2 Number: (3 Digit Code)



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