1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Delivery / Contact InformationWe will now ask you some questions to assess your suitability for a prescriptionBefore you start, it is important that you read this:Welcome to our online clinic. This questionnaire forms the basis of today's consultation. We need you to be honest with your answers so we can prescribe medication safely and give you the right advice. If you forget to tell us something or give inaccurate information, this may result in a drug being prescribed that harms rather than helps you. It's important that you tell us about any medication you are already taking, as certain drugs cause serious reactions with Xenical.Xenical will only work when used as part of a weight management plan. It should only be taken by people who are overweight.I understand and agree to answer questions honestly and fullyYesNo Your ConditionPlease enter your height and weightMetric (cm + kg)Imperial (Feet / Stone)Height (cm)*Weight (kg)*Height (Feet / Inches)Weight (Stone / Pounds)Have you taken or are you taking Xenical to help you lose weight?*NoYesDid Xenical help with your weight loss? Name any side effects experienced when taking the medication*Have you ever tried any other weight loss programmes, whether it be dieting, exercising or other medication?*NoYesPlease state what you have tried. It is important to note that exercise and healthy eating form a vital part of weight loss even when taking Xenical.*Your HealthAre you currently taking any prescription-only medicines, alternative medicines or recreational drugs?*NoYesPlease provide information*Please state all medication / drugs you are currently taken. This is vital information as it may be that some medicines cause severe reactions if taken in conjunction with Xenical.Do you have any known allergies?*NoYesPlease provide information*Please state all known allergies. We need to make sure there are no ingredients in Xenical which may cause an allergic reaction.Do you have any history of kidney or liver conditions?*NoYesPlease provide information*Have you ever been diagnosed with chronic malabsorption syndrome? (problems with absorbing your food)*NoYesPlease provide information*Have you ever been diagnosed with gallbladder, bile duct or pancreas disease?*NoYesPlease provide information*Have you ever been diagnosed, or do you currently suffer with an eating disorder such as anorexia or bulimia?*NoYesPlease provide information*Are you pregnant, planning to become pregnant or breastfeeding?NoYesN/APlease provide information*ConsentI agree to the site's terms and conditions. I confirm I am over 18 years old. The medicine ordered is for my sole use only. I will read the patient information leaflet supplied with the medicine or obtain it from the website; I will especially take note of the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.NoYes I AgreeI confirm that the treatment I have requested is for my sole use only and that I have not completed this questionnaire on behalf of another person.*NoYesI understand that Xenical forms part of a weight loss programme which shuold include lifestyle modifications such as a healthy diet and an exercise programmeNoYes Price*Xenical (Orlistat) 120mg - 28 day supply - £65.00Xenical (Orlistat) 120mg x 56 day supply - £125.00Xenical (Orlistat) 120mg x 84 day supply - £160.00Orlistat 120mg 28 day supply - £45.00Orlistat 120mg 56 day supply - £75.00Orlistat 120mg 84 day supply - £100.00Prescription Charge £ 5.00Total £ 0.00 Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.