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Full Name
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First Name
Last Name
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2
E-mail
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3
Where did you place your order?
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healthpharm.co.uk
Other
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4
Is the medicine for you?
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5
What is the age of intended user?
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6
Is the intended user taking any other medication, including
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7
Please specify these here
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8
Does the intended user suffer from any medical conditions?
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9
Please specify these here
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10
Please enter the intended users height in Meters
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1 foot = 0.3048 meters eg. 5.6ft = 1.7 meters (5.6 x 0.3048)
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11
Please enter the intended users weight in kg
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1 stone = 6.35029318 kilograms eg. 7.4stone = 46.99kg (7.4 x 6.35029318)
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12
Do you have an allergy to Orlistat or any of the other ingredients?
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A full list of ingredients is available online at www.alli.co.uk/FAQs/Ingredients/
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13
Do you suffer with chronic malabsorption syndrome (condition which causes problems absorbing food)?
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Yes
No
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14
Do you suffer with cholestasis (condition where the flow of bile from the liver is blocked)?
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Yes
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15
Are you pregnant or breastfeeding
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16
I understand that alli should be used with caution with the oral contraceptive pill. Contraception may fail if you experience diarrhoea.
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I confirm and understand this
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