Direct Response Marketing (Jersey) Limited, jersey, channel islands. Mail Order Online Pharmacy. Viagra, Propecia, Cialis, Uprima, Xenical, Avodart, Regaine (Minoxidil). Treatments for impotence, hair loss and weight loss.
All major Credit Cards accepted
SAME DAY DESPATCH FROM OUR BRITISH PHARMACY BEFORE 1PM (NOT INCLUDING HOLIDAYS/WEEKENDS)
If you have any problems, please Email DRM to let us know.
This is a secure form that uses server encryption to protect your personal data (check that the address starts https:// )
WEIGHT LOSS - MEDICAL DECLARATION
PLEASE COMPLETE THIS FORM FOR ALL WEIGHT LOSS DRUG REQUESTS - YOU WILL THEN BE ABLE TO REQUEST YOUR DRUGS AND COMPLETE YOUR ORDER
Please complete all the following fields;
(Fields marked IN RED (*) are mandatory)
(If outside these ranges - please specify in comments field below)
Click here to check your Body Mass Index NOTE; The Doctor is unlikely to prescribe Xenical for any first-time user with a BMI below 26.
(Briefly) By what other means have you tried to lose weight? and how much did you lose?.
What sex are you? (YOUR GENDER - MALE or FEMALE)
Date Of Birth.
Do you have any known allergies?
Do you now suffer from, or have you ever received treatment for high blood pressure??
Do you now suffer from, or have you ever received treatment for Anorexia/Bulimia/any other eating disorder?
Do you suffer or have you ever suffered from Chronic malabsorption syndrome/Cholestasis/Ulcerative Colitis?
Are you currently Breast-feeding
Have you taken any anti-depressive medication within the last 8 weeks? (If yes, please specify below)
Have you been prescribed Xenical before?
(Any previous prescription, either from your own doctor or from another supplier)
Is there any reason why you believe you may not be able to take XENICAL??
DRM advise you to discuss any concerns about this questionnaire or the use of Xenical with your own Doctor.
Check this box if you would like the doctor to contact you about your condition.
you can also contact our doctor for more advice at any time by using this link Email Doctor
Please use this field to add details of any medication taken or to expand further on the above questions if necessary, or to tell us more about your problem so that our doctor can help you further.
Standard medical practice requires your General Practitioner / Doctor to be aware of any medication prescribed to you.
I take responsibility for informing my G.P. / Doctor
If you have selected "NO", you must enter your doctors name and address below, so that DRM can inform them
I confirm that I have read and understood the information given and that the above information is the truth to my certain knowledge.
I know of no reason why I should not be prescribed this product and I take full responsibility for my use of the product as recommended by the manufacturers.
I believe that this consultation by the DRM appointed doctor is in my best interest as a patient and I consent to my data being processed by DRM and being made available to the DRM appointed Doctor(s) and/or Pharmacy.
I have read and understood the product information given regarding the use of this product by both DRM and the manufacturer, and I will read the packaging and enclosed leaflet before use.
For more information read our privacy page
By typing your name here you confirm your acceptance of the above statements
Please enter your phone and email address here, so that we can contact you if necessary (we are required by our doctor to follow up on your treatment)
Daytime Telephone Number*
TOTAL DISCRETION IS ASSURED - YOUR DETAILS WILL NEVER BE PASSED ON TO A THIRD PARTY.
Direct Response Marketing (Jersey) Limited.
Suite 15 Burlington House, St Saviours Road, St Helier, Jersey, British Channel Islands. JE2 4LA
Telephone; 0845 121 6667 (UK local rate)
Fax; 0845 121 6669 (UK local rate)
International Telephone (44) 1534 510271
General Enquiries - email: Email DRM: Order Enquiries - email: Email order dept All trademarks are acknowledged as the property of their respective owners.