2.  I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of  Xenical,  and I hereby agree to answer truthfully all of the questions on my questionnaire.

3.  I understand that no doctor can guarantee that Xenical, even if prescribed, will provide the results I seek.  I acknowledge that no guarantees have been made to me as to the results as there is no known medical treatment that gives 100% satisfaction to everyone, nor are there any guarantees against unfavorable results, risks or complications.

4.  I understand that although no serious adverse reactions have been reported to date, even if prescribed, I may suffer adverse effects from Xenical.   Adverse effects are mainly gastrointestinal  such as fatty/oily stool, increased defecation, fecal urgency, fecal incontinence, oily spotting and flatus with discharge.  These reactions are usually mild and transient and do not indicate stopping therapy.

5.  I further acknowledge that if I am prescribed Xenical by Advanced Xenical , I have full knowledge that no physician, nurse or medical personnel can predict as whether I would or would not have any adverse effects since every individual has a unique biological/chemical make-up.  I understand that all possible risks and/or complications do not need to be explained to me, nor do I consider this practical or even possible because risks and complications may occur that have never been recorded before. I hereby release  Advanced Xenical and any associated physicians from any and all liability whatsoever with any adverse effects I may suffer from my use of Xenical.

6.  I am participating in this Advanced Xenical program at my own choice, at my own expense and my own liability and assume all responsibility for my use of Xenical.  I acknowledge and agree that I initiated this contact with Advanced Xenical , and I agree that all on-line medical consultations and treatments will be deemed to have occurred in the state where the physician is physically located and licensed to practice medicine which may be in another state from my own.

7.  I fully understand that it is my responsibility to have routine physical examination to ensure that I have no disease(s) which might make Xenical inappropriate for my condition.  I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I do not have any conditions or I am not taking any medications that would make Xenical contraindicated.  I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Xenical.

8.  I further understand that it is recommended that I take a Vitamin supplement with Xenical, preferably at night so that Xenical does not interfere with the absorption of fat-soluble vitamins.

9.  I understand that if I have failed in any way to provide Advanced Xenical with my complete and accurate medical history or if I fail to notify Advanced Xenical of any changes in the future, then I can not hold Advanced Xenical or  its physicians responsible for any adverse effects I may suffer and I am solely responsible for any adverse effects I may suffer from taking or continuing to take Xenical or from participating in this program.

10. If after review of my consultation questionnaire, a physician determines that Xenical is appropriate treatment, I hereby authorize a  one time charge of $59.95 plus S&H processing fee  to be charged to my credit card for this physician consultation.  I understand that I must always submit my assigned membership number when requesting FREE written Xenical prescriptions which can be taken to any US pharmacy and filled in the exact same customary manner as one would fill any written prescription received from a physician.  Also, I understand that this one time consultation fee entitles me to unlimited free refill prescriptions until I reach a healthy ideal weight determined by BMI as long as I have my assigned membership number and meet the guidelines set by Roche Laboratories. 

11. I hereby waive a physical exam at this time  and agree to continue to have routine medical examinations by my regular physicians.

12. I hereby understand that I must continue with my regular health care visits to my own physician and that I must inform all treating physicians as well as my primary care physician that I am taking Xenical.

13. I fully understand that being overweight puts me at increase risk for many diseases, on of which is gall bladder disease.   While losing weight the risk of suffering from gall bladder disease my increase as high as 38%.  I acknowledge that I have been fully warned about this possible outcome which is the development of gall bladder disease, gall stones and possibly necessitating removal of the gall bladder.

14.  I have read the contraindications which are history of  hyperoxaluria or calcium kidney stones, intestinal malabsorptions syndromes, cholestasis or active gall bladder disease, pregnancy, nursing mothers and those currently suffering from anorexia nervosa or bulimia.