In order to prescribe your drugs without risk,
the following information will be required by the doctor of perscription. You must answer all the questions completely and exactly.
|
|
|
|
|
|
|
| Patient Information |
|
|
|
|
|
|
|
|
|
|
|
| Todays Date (mm/dd/yy): |
|
| Your email address: |
|
| Your first and last names: |
|
| Address ( No PO boxes ): |
|
| City: |
|
| Province/state: |
|
| Country: |
|
| Postal code: |
|
| Home Telephone number: |
|
| Work Telephone number: |
|
| Date of birth (dd/mm/yy) : |
|
| Height |
Ft in |
| Sex: |
|
| Occupation: |
|
Primary Physician
(please write the name of the doctor, the
address, the telephone number, and the email if it is avaliable.)
|
Are you a returning customer?
( if you are jump to
the medical waiver ) |
|
|
| Medical data of the patients family. |
| Diabetes, thyroid or different: |
Yes |
no |
Disorder Of Endocrine: |
Yes |
no |
| Hypertension: |
Yes |
no |
Disorder Of Lipid: |
Yes |
no |
| The cardiovascular disease: |
Yes |
no |
Cancer of prostate: |
Yes |
no |
| The other shapes of cancer: |
Yes |
no |
Other diseases no previously remarkable: |
Yes |
no |
|
|
|
|
|
|
|
|
|
|
|
|
| Patient medical information |
| Do you have a history or currently have the following? |
| Diagnosed with a tumour: |
Yes |
no |
Disorders of blood: |
Yes |
no |
| Cancer: |
Yes |
no |
Immune disorders: |
Yes |
no |
| Poor wound healing: |
Yes |
no |
Liquid conservation of Edema/excess: |
Yes |
no |
| Hypeplipidemy: |
Yes |
no |
Respiratory superior: |
Yes |
no |
| respiratory problems |
Yes |
no |
Hypertension: |
Yes |
no |
| Renal disease: |
Yes |
no |
Heart attack: |
Yes |
no |
| Emotive disorders: |
Yes |
no |
Genital-urinary disorder: |
Yes |
no |
| Glaucome: |
Yes |
no |
Carpal Tunnel Syndrome: |
Yes |
no |
| Surgery: |
Yes |
no |
Drug Allergies: |
Yes |
no |
| Other diseases no yet marked: |
Yes |
no |
Chemical dependence: |
Yes |
no |
|
|
|
| Neurological disorders, thyroid, tiabetes or
any other disorder of endocrine including/understanding the insulin
resistance, or diabetes: |
Yes |
no |
| Any known insufficiency, including mineral and
electrolytes: |
Yes |
no |
| Orthopedic disorder or of muscle, including the
rupture or the disorders of joint: |
Yes |
no |
| Cardiac disorder, including the
altherosclerosis, angina, cardiac arrest: |
Yes |
no |
|
| Please explain the "yes" answers to the
questions above: |
|
|
| Regular exercise: |
|
|
|
Yes |
no |
| Drugs used currently and in last 12 months: |
|
|
|
Yes |
no |
| Preceding loss of weight: |
|
|
|
Yes |
no |
|
| Loss of concentration, sociability, activity: |
Yes |
no |
Increasing mood swings: |
Yes |
no |
Short term memory loss:
Short Term
In the long run |
Yes |
no |
Increasingly subjected to stress |
Yes |
no |
| Long term memory loss: |
Yes |
no |
Difficulty sleeping: |
Yes |
no |
Reduced desire and capacity for exertion:
|
Yes |
no |
Decreasign sex drive: |
Yes |
no |
| Decreased sense of wellbeing: |
Yes |
no |
Depression: |
Yes |
no |
| Loss of interest in sex: |
Yes |
no |
Inablility to maintain erections: |
Yes |
no |
| Decreasing size of the testicles: |
Yes |
no |
Loss of morning and or night erections:
|
Yes |
no |
| Normal level of PSA in the last 12 months: |
Yes |
no |
To thin or loss of hair: |
Yes |
no |
| Intolerance of cold or heat: |
Yes |
no |
Sagging, loose or thin the skin: |
Yes |
no |
| Increasing wrinkles: |
Yes |
no |
Loss of muscle: |
Yes |
no |
| Increasing muscles of bending: |
Yes |
no |
Decreasing muscle strength: |
Yes |
no |
|
| Decreased energy or endurance: |
Yes |
no |
| Progressive Osteoporosis, decreasing mass of
bone: |
Yes |
no |
| Increasing layers of fat about abdomen or
thighs: |
Yes |
no |
|
| I read and understand the medical waiver and agree on all
its terms: |
Yes |
no |
|
|
Mailing information
(if different from above)
|
|
| First name: |
|
| Last name: |
|
| Address line 1: |
no PO Boxes |
| Address line 2: |
no PO Boxes |
| City: |
|
| Province/state: |
|
| Country |
|
| Postal code: |
|
| Telephone: |
|
|
|
The information of payment
|
|
|
Method of payment: |
|
| Credit card number: ( no spaces or dashes) |
|
| CVV2 numbers: |
what is it? |
| Expiration date: |
|
| Promotional code: |
|
Billing Address
(if different from above)
|
|
| First name: |
|
| Last name: |
|
| Line 1 of address ( exactly as it
appears on your credit card bill ): |
no PO Boxes |
| Line 2 of address (optional) |
no PO Boxes |
| City: |
|
| State/province/region: |
|
| Country |
|
| Postal code: |
|
|
Choice of product 60-day supply of Restorin - $220
90-day supply of Restorin - $330
The prices include the
following fees of regulation :
60 and 90 day supplies: $10
The FedEx shipping and duties will
be added to the order as follows:
(noe: The following countries will no allow the
entry of the product; Australia and Norway.)
| |
Shipping |
Duties |
| The United States |
23,59 |
0 |
| Belgium |
26,34 |
47.38 |
| Canada |
23,59 |
19,88 |
| Estonia |
44,30 |
0 |
| Hong Kong |
28,89 |
0 |
| Japan |
44,03 |
0 |
| New Zealand |
29,49 |
0 |
| Puerto Rico |
23,59 |
11,60 |
| The United Kingdom. |
25,97 |
34,97 |
| All Others |
30,00 |
0 |
|
|
|
|
