Pharmacy Select

Buy Phendimetrazine Online Order Form
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Choose a Medication

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Domestic Orders - there is a $18.00 shipping and processing fee. Please allow 1-2 business days for delivery.

Medical History
Please enter your Height:	your weight in pounds:	lbs
date of birth

Sex:

Do you have high blood pressure?

Yes

I agree not to take any over-the counter medicines without approval from my pharmacist.:

Yes

I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately.

Yes

I agree to not take this medication if I am pregnant, breast feeding, or trying to get pregnant.

Yes

Please list any current medical conditions:

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Please list all medications that you plan to take while on this program:

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Weight loss specific questions

Click here to calculate bmi enter your bmi

You must have a bmi of 27.0 or greater to qualify for weight loss medications.

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