AlinRx.com Attached Medical Form 
(information on female taking the medication)
--------------------------------

Gender:
Date Of Birth:
Height:
Weight:
Do you Smoke?:
Do you Drink?:
How is your blood pressure?:
Do you suffer from Allergies?:
     (If yes,  please detail):

What is your primary purpose for taking this medication?:

Are you currently taking any other medication?:
     (If yes, please detail):

Do you agree to the TOS Terms of Service by ordering through AlinRx.com
Escrow Service? (located at AlinRx.com/legal):

Do you understand ALL RISK involved in having a medical abortion and that you are ordering the medication knowing these risk?