1.Your e-mail address 

2.How many Alli (42) packs  would you like to order   1     

Please select an age 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 years 0 1 2 3 4 5 6 7 8 9 10 11 12 months    Are you pregnant or breastfeeding ?  Yes  No

3.Please confirm your BMI (body mass index). If you don’t know it, please provide your weight and height .NB .ALLI is only suitable for adults with  a BMI of 28 or above
  

4.Existing Conditions - Are you  currently suffering from any medical conditions, please list them here. 
 

5.Other Medicines -are you taking any  medication either prescribed or purchased? Please enter details 
 

6 Any Allergies -Do you suffer or have you ever had any allergies to medicines , if so please state
   

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