Click Here to Read The Patient Responsibility Statement. I have Read, Understand and Agree
Yes
No
Click Here to Read The Informed Consent. I have Read, Understand and Agree
I would like to recieve promotional e-mail with information about health tips, new site features and special product promotions.
Shipping Information
Your Email Address:
First Name
Last Name
Address: (No P.O. Boxes Please)
City:
State:
Choose State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Day Time Phone
Work Phone:
Billing Information
Same as Shipping Address
Address:
Credit Card Type:
Visa Master Card American Express Discover
Card Number:
Expiration Date:
Card Holder's Name:
Please select the product and quantity that you would like to order:
Choose a Medication
Additional Meds
Choose One Adipex 37.5mg 30 Tablets +$145.00 Adipex 37.5mg 90 Tablets +$268.00 Bontril SR 105mg 30 Tablets +$99.00 Bontril SR 105mg 90 Tablets +$175.00 Didrex 50mg 30 Tablets +$105.00 Didrex 50mg 60 Tablets +$160.00 Didrex 50mg 90 Tablets +$175.00 Ionamin 30mg 30 Tablets +$139.00 Ionamin 30mg 30 Tablets +$149.00 Ionamin 30mg 90 Tablets +$278.00 Meridia 10mg 30 Tablets +$175.00 Meridia 10mg 90 Tablets +$350.00 Meridia 15mg 30 Tablets +$225.00 Meridia 15mg 90 Tablets +$450.00 Phendimetrazine 35mg 90 Tablets +$95.00 Phentermine 30 mg. 30 Tablets +$75.00 Phentermine 30 mg. 90 Tablets +$150.00 Phentermine 37.5mg 30 Tablets +$99.00 Phentermine 37.5mg 60 Tablets +$160.00 Phentermine 37.5mg 90 Tablets +$198.00 Renova 40gm Tube +$112.00 Retin A Microgel (.1%) 45gm Tube +$125.00 Valtrex 500mg 30 Tablets +$175.00 Valtrex 500mg 90 Tablets +$450.00 Vioxx 12.5mg 100 Tablets +$400.00 Vioxx 12.5mg 200 Tablets +$750.00 Vioxx 12.5mg 50 Tablets +$225.00 Vioxx 25mg 100 Tablets +$400.00 Vioxx 25mg 200 Tablets +$750.00 Vioxx 25mg 50 Tablets +$225.00 Zyban 150mg 60 Tablets +$175.00 Tenuate Dospan 75mg 30 Tabs = $99.00 Tenuate Dospan 75mg 90 Tabs = $199.00 Viagra 100mg 10 Tablets Viagra 100mg 20 Tablets Viagra 100mg 30 Tablets Xenical 120mg 60 Capsules Propecia 1mg 30 Tablets Propecia 1mg 90 Tablets Celebrex 100mg 50 Tablets Celebrex 200mg 100 Tablets Celebrex 200mg 200 Tablets None
Growth Hormone - a shipping charge of $25.00 will be added to each order for FedEx next day delivery. Growth Hormone requires special shipping i.e. refrigeration. We do not ship Growth Hormone to International countries.
Medical History
Please enter your Height:
your weight in pounds:
lbs
date of birth Month Jan Feb March April May June July Aug Sept Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Do you have high blood pressure?
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 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.
I agree to not take this medication if I am pregnant, breast feeding, or trying to get pregnant.
Please list all medications you are currently taking:
Please list all medications that you plan to take while on this program:
Please list all allergies (including medications):
Please list any surgeries:
Is there anything else in your medical history you deem relevant?
Click here to calculate bmi enter your bmi
You must have a bmi of 27.0 or greater to qualify for weight loss medications.
Viagra specific question
Do you have any of the following conditions? Luekemia, Multiple Myeloma, Sickle cell Disease, Peptic Ulcers, or Retinitis Pigmentosis?
Do you take any form of nitroglycerine?
Have you previously been treated for sexual dysfunction?.
