XENICAL-SALES.COM

MEDICAL DECLARATION

TITLE .............FIRST NAME(S) ........................................... FAMILY NAME ...........................................

* Date Of Birth. .......... / .......... /.......... EMAIL .....................................................

* Your height....................(M /ft) Your weight........................(Kg/Lbs) Please indicate units.

*ADDRESS ........................................................................................................

........................................................................ POST / ZIP CODE ..........................

*TEL.NO .................................................. FAX ........................................................

Do you suffer from any of the following (or any associated condition)?

please write YES or NO clearly in the space provided for ALL questions.

*DO YOU SUFFER FROM DIABETES?
______

*LIVER DISEASE?
______

*BOWEL DISORDERS?
______

*UNDER-ACTIVE THYROID?
______

*VITAMIN DEFICIENCY?
______

*CROHN'S DISEASE?
______

*ULCERATIVE COLITIS?
______

*ARE YOU PREGNANT OR BREAST-FEEDING?
______

*IS THERE ANY HISTORY OF BREAST CANCER IN YOU FAMILY?
______

*ARE YOU TAKING STEROIDS?
______

*IS THERE ANY REASON WHY YOU BELIEVE YOU MAY NOT BE ABLE TO TAKE XENICAL?

DRM advise you to discuss any concerns about the questionnaire or the use of XENICAL with your own doctor.
______

PLEASE GIVE DETAILS IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS.

PLEASE LIST ANY MEDICATION YOU ARE CURRENTLY TAKING (PRESCRIBED OR OVER-THE-COUNTER)

Standard medical practice requires your General Practitioner / Doctor to be aware of any medication prescribed to you.

PLEASE SELECT ONE OF THE FOLLOWING OPTIONS

* I take responsibility for advising my G.P./ Doctor.
YES / NO

*I would like DRM to advise my G.P./Doctor

His / Her name and address are;-

YES / NO

I confirm that I have read and understood the information given and that the above information is the truth to my certain knowledge. I accept full responsibility for my use of the supplied drugs. I am over 18 years of age.

*Signed____________________

*Date_____________________

*= mandatory

TOTAL DISCRETION IS ASSURED - YOUR MEDICAL DETAILS WILL NEVER BE PASSED ON TO A THIRD PARTY

ABOUT DRM

ABOUT XENICAL

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ORDER FORM

XENICAL

PLEASE INDICATE THE QUANTITY YOU REQUIRE;-

FOUR WEEKS (28 DAYS) SUPPLY = £145.00
_____

£ = $?, FrF?, Kr?, DM?, YOUR COUNTRIES CURRENCY? - EXCHANGE - CHANGE - CONVERT

NO! SEPARATE CONSULTATION FEE - NO! HIDDEN COSTS - POSTAGE AND PACKING TO ANY COUNTRY INCLUDED!

OTHER CURRENCIES? -- Orders will be applied to your credit card in UK pounds, the amount wil be automatically debited (in your own currency), at the rate prevailing on the day of transaction by the credit card company -

(DRM are not responsible for local taxes or import restrictions which may apply in your country)

I enclose cheque/PO for £________ payable to 'DRM Ltd'

or

Please debit my Access / Visa / Mastercard No ............. / ............. / ............. / .............

Expires ............. / ..............

DESPATCH TO;

NAME ..................................................................................................................

ADDRESS ............................................................................................................

.............................................................................................................................

COUNTRY...............................................................................................................

POST CODE ................................. EMAIL ...........................................................

NAME & ADDRESS ON CREDIT CARD (if different) ...............................................

.............................................................................................................................

.............................................................................................................................

HAVE YOU ORDERED via drm BEFORE ? - - - YES / NO

HOW DID YOU LEARN OF DRM?... Search engine / Newspaper / Magazine / Website link / Other

Please Specify ..............................................................................................................................

Fax or post your completed forms to;-

Direct Response Marketing (Jersey) Limited.

Suite 15 Burlington House,

St Saviours Road,

St Helier,

Jersey. Channel Islands.

JE2 4LA.

Telephone; 0845 121 6667 (UK local rate)

Fax; 0845 121 6669 (UK local rate)

International Telephone (44) 1534 510271

International Fax (44) 1534 510272

General Enquiries - email: Email DRM
Order Enquiries - email: Email order dept
home

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ABOUT DRM

ABOUT XENICAL

Direct Response Marketing - Home

General Enquiries - email: Email DRM

Order Enquiries - email: Email order dept


XENICAL is the trademark of F. Hoffmann-La Roche Ltd Propecia is the trademark of Merck & Co., Inc. Viagra is the registered trademark of Pfizer Inc. NY. All other trademarks are acknowledged as being the property of their respective owners

ORDER VIAGRA : ORDER XENICAL : ORDER PROPECIA : ORDER UPRIMA : ORDER REGAINE (Minoxidil) :
PRODUCT INFORMATION : OTHER PRODUCTS? : LOST? - SITE MAP : DRM HOME

*DO YOU SUFFER FROM DIABETES?	______
*LIVER DISEASE?	______
*BOWEL DISORDERS?	______
*UNDER-ACTIVE THYROID?	______
*VITAMIN DEFICIENCY?	______
*CROHN'S DISEASE?	______
*ULCERATIVE COLITIS?	______
*ARE YOU PREGNANT OR BREAST-FEEDING?	______
*IS THERE ANY HISTORY OF BREAST CANCER IN YOU FAMILY?	______
*ARE YOU TAKING STEROIDS?	______
*IS THERE ANY REASON WHY YOU BELIEVE YOU MAY NOT BE ABLE TO TAKE XENICAL? DRM advise you to discuss any concerns about the questionnaire or the use of XENICAL with your own doctor.	______
PLEASE GIVE DETAILS IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS. PLEASE LIST ANY MEDICATION YOU ARE CURRENTLY TAKING (PRESCRIBED OR OVER-THE-COUNTER)

Standard medical practice requires your General Practitioner / Doctor to be aware of any medication prescribed to you.
PLEASE SELECT ONE OF THE FOLLOWING OPTIONS
* I take responsibility for advising my G.P./ Doctor.	YES / NO
*I would like DRM to advise my G.P./Doctor His / Her name and address are;-	YES / NO

XENICAL-SALES.COM

MEDICAL DECLARATION

TITLE .............*FIRST NAME(S) ........................................... *FAMILY NAME ...........................................

* Date Of Birth. .......... / .......... /.......... EMAIL .....................................................

* Your height....................(M /ft) Your weight........................(Kg/Lbs) Please indicate units.

*ADDRESS ........................................................................................................

........................................................................ POST / ZIP CODE ..........................

*TEL.NO .................................................. FAX ........................................................

ORDER FORM

XENICAL

TITLE .............FIRST NAME(S) ........................................... FAMILY NAME ...........................................