w1

Please chose Your Order

—Please choose an option—Fio – 180 – $249Fio (White) – 180 – $249Fio (Blue) – 180 – $249Fio – 120 – $219Fio – 90 – $179Gab 600 – 180 – $195Gab 800 – 180 – $199Gab 300 – 180 – $169Gab 400 – 180 – $179BAC10 – 180 – $189BAC20 – 180 – $209CYC10 – 180 – $159ZAN4 – 180 – $156ROB750 – 180 -$168

Please confirm your order

—Please choose an option—Fio – 180 – $249Fio (White) – 180 – $249Fio (Blue) – 180 – $249Fio – 120 – $219Fio – 90 – $179Gab 600 – 180 – $195Gab 800 – 180 – $199Gab 300 – 180 – $169Gab 400 – 180 – $179BAC10 – 180 – $189BAC20 – 180 – $209CYC10 – 180 – $159ZAN4 – 180 – $156ROB750 – 180 -$168

1. I want to pay you by:

COD

Personal Details

Your First Name :

Your Last Name :

Your Email :

Your Phone:

Your Zip Code:

Billing and Shipping Address

Street Address:

City:

State:

Country:

Health Questionnaires

Date of Birth: mm/dd/year

Your Height: ft-in

Your Weight: Lbs

Gender: —Please choose an option—MaleFemale

1. I agree not to take any over-the-counter medicines without approval from my pharmacist.

I AgreeI Disagree

2. I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant.

I AgreeI Disagree

3. Please list all current medical conditions including high blood pressure. Choose “None” if none.

NoneI will specify

Specify all current medical conditions:

4. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose “None” if none.

NoneI will specify

5. Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Choose “None” if none.

NoneI will specify

6. Please list all medications that you plan to take while on this program. Choose “None” if none.

NoneI will specify

7. Please list all past or present allergies including allergies to any medications. Choose “None” if none.

NoneI will specify

8. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose “None” if none.

NoneI will specify

9. Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. This cannot be left blank.

I double checked the information and confirm all the information is correct , and I will pay you a money order when I pick up the drugs. I also know the order cannot be cancelled and all the information I input can not be modified after I click “place order now” link.