Non-Secure Order Form

To order Xenical from Xenical News simply fill out the order form to send your order by electronic mail or you can print the order form out and fax it to us at (877) 644 8783.

Worldwide standard mail delivery normally takes approximately 7 to 14 working days to most countries. We also offer courier service taking approximately 4-5 working days. All prices listed are in US dollars.

For all new patients, a $50.00 doctors consultation fee will be accessed. If you are a previous customer, please use this form, submitting your customer number when requested

Xenical (Orlistat)
Xenical (Orlistat)
120mg x 84 tablets
One months supply   $110.00
Two months supply   $200.00
Three months supply   $290.00
Six months supply   $570.00
Please fill out your medical details.
[ Your Doctor's name and Phone number are optional but may expedite shipping ]
Age:
Height:
Weight:
Are you taking steroids?
Yes: No:
Are you pregnant or breast feeding?
Yes: No:
Do you suffer from Anorexia Nervosa?
Yes: No:
Do you have any liver disease?
Yes: No:
Do you have any bowel disorders?
Yes: No:
Do you have Crohns Disease?
Yes: No:
Do you suffer from mal-absorbtion due to intestinal conditions?
Yes: No:
I accept that Xenical is much less likely to be effective without a lifestyle change.
Yes: No:
I understand that with a high fat intake, diarrhoea , bloating and faecal incontinence are possible side-effects.
Yes: No:
I understand that Xenical should be used in conjunction with a reduced calorie diet and a program of regular physical activity.
Yes: No:
I accept that there is a rare possibility of an as yet unreported serious side effect of taking Xenical.
Yes: No:
Your Doctor's Name:
Your Doctor's Phone:
Current Medication:
Other Relevant Medical Information:



Doctors Consultation
[ You will require a medical consultation unless we've already issued you with a prescription. ]
Yes, I require a medical consultation.   $50.00
No, I have already paid for a medical consultation with Xenical Pharmacy. My customer number is:  
Shipping Method
Regular Mail (approx 7-14 working days)   $3.00
Customer Details
Name:
Street Address:
 
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
E-mail
Payment Type:
Cardholders Name:
Credit Card Number:
Expiration Date:
 / 
Comments & additional instructions:
[ Due to restrictions imposed, Xenical Pharmacy cannot ship to Taiwan ]
I would like to receive periodical e-mails about special offers on Xenical, and other weight loss products.
You will be able to opt-out of this at any time you wish simply by e-mailing us with the text 'REMOVE' in the message. Your personal information (Including E-mail address) will not be sold or in any other way disclosed to anybody outside of XenicalPharmacy.
I hereby release The Xenical Pharmacy and all of its employees including contractors and physicians from any and all liabilities connected with my consultation and purchase.
I take responsibility to advise my Physician/Doctor of any medication I am taking including Xenical.