PharmacyHealth.net Medical Questionnaire/Order Request
  The information below is needed to place your order request for medication.
We will not disclose any personal information to any outside party.
See our privacy statement for additional information.

All fields below must be filled out for order requests.
  Section 1: customer account information
First Name:  (Complete First Name - No Initials)
Last Name:
Email Address: (Like yourname@aol.com)
 
NOTE: To keep you informed, we provide e-mail notifications concerning your medical consultation and order status.
Date of Birth: / /
Gender:


  Section 2: shipping/contact information
Shipping Method:
 
NOTE: You will be required to sign for delivery.  There will be a $10.00 charge if an address change is necessary after submission and confirmation of your order.
Shipping Address:  
Street Address: (No P.O. Boxes)
 
City:
State:
Province: (Non U.S. use only)
Zip Code:
Country:
Day Time Phone: () -  Ext.
Evening Phone: () -  Ext.


  Section 3: payment method
Payment Method:
Card Holder: (Exact Name on Credit Card Bill)
Card Number:
CVV2: (The 3 digit number on the back of your card) More Info
Expiration Date:
Billing Address:  
  Same as Shipping Address
Address:
Address 2:
City:
State:
Province: (Non U.S. use only)
Zip Code:
Country:


  Section 4: your medication selection
Please select the product and quantity that you would like to order:
Medication:


  Section 5: medical questionnaire
Please select your Height:
Please enter your Weight in pounds: Lbs.
NOTE: Customers must have a body mass index of 25 or greater to request a weight loss medication.
Your Calculated Body Mass Index (BMI):
(Automated calculations, please click on box)


  Section 6: customer agreements
To place an order, you must agree with the Customer Responsibility and Informed Consent Statements below.
Click each link to view the documents in a pop-up window.


I Have Read, Understand and Agree with the Customer Responsibility Statement


I Have Read, Understand and Agree with the Informed Consent Agreement


I would like to receive promotional e-mail with information about health tips, new site features and special product promotions.


 

Click "Review/Confirm Order" to review your order request.
Credit Card will be billed by Medline Financial.