Pharmcom - Xenical and Propecia available online.

Welcome to Pharmcom by Mail Order.

With this page you can place an order for Xenical and send it to Pharmcom by post or fax. You can make payment by credit card or you can send your order by post and include an international money order or a cashiers check.

To place an order, please fill in your details below, print out this page and post it to:

Pharmcom International
P.O.Box 100-169
North Shore Mail Center
Auckland 1310
New Zealand

Alternatively you can fax your order to Pharmcom on ++ 649 479 1083 . If you are faxing from the United States, please replace the '++' with 011.



	First name(s):

	Surname:

	Address:

	City:

	State/Region:

	Postcode:

	Country:

	Email:


	Age:

	Weight:

	Height:

	Tel (inc area code):

	Fax (inc area code):

	Do you suffer or have you ever suffered from Anorexia Nervosa or Bulimia ?	No Yes

	Do you suffer from any Malabsorption Syndrome (eg Idiopathic Steatorrhoea or Tropical Sprue) ?	No Yes

	You should not breastfeed your infant during treatment with Xenical as it is not known whether Xenical is secreted in human milk. Are you currently breastfeeding, or do you intend to be doing so in the near future ?	No Yes

	Do you take the medidine Cyclosporine (Neoral, Sandimmune, SangCya)?	No Yes

	Do you suffer from the medical condition Cholestasis or any disorder of the gallbladder? Answer "No" if you have had your gallbladder removed	No Yes

	Do you suffer from Hypothyroidism? Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone	No Yes

	Known Allergies:

	Current Medications: Please list all prescription and non-prescription ("over the counter") medications you are currently taking, even if only occasionally.

	Do you have any medical conditions, particularly diabetes, or high cholesterol levels. If so please give details. If you are unsure, you should ask your regular doctor.

	Do you consider anything else in your medical history to be relevant. Please give details

	Select Quantity:

	Select method of payment:

	Credit card number:
	Expiration date:

	Delivery instructions (if any):

	After you have completed your order details, please print out this page and fax or post it to Pharmcom.


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