|
Please print out and complete the following forms. These
can be either faxed or posted to Menscare Services.
- By Fax:
Print out the order form and fax it to 01889
562036,
sending payment to:
Menscare UK LTD. 57 Balance Street, UTTOXETER, Staffordshire,
ST14 8JQ
Make your cheque or postal order payable to: Menscare
UK LTD
By mail:
Print out the order form and post it with your payment to:
Menscare UK LTD. 57 Balance Street, UTTOXETER, Staffordshire,
ST14 8JQ
Make your cheque or postal order payable to: Menscare
UK LTD
Waiver of Liability
I hereby release Menscare Services and all of its employees
and contractors including physicians from any and all liability whatsoever associated or connected with my Viagra
Consultation and/or my use of Viagra. I hereby state that I am an adult and that I am aware of the potential side
effects associated with Viagra. I hereby agree to answer truthfully all of the medical questions on my questionnaire.
I understand that no doctor, nurse, or administrative personnel can guarantee that Viagra, even if prescribed,
will provide the results I seek. Further, I understand that even if prescribed, I may suffer adverse effects from
Viagra. I hereby release Menscare Services and all of its employees and contractors including physicians from any
and all liability whatsoever associated with any adverse effects I may suffer from my use of Viagra.
I am submitting this questionnaire at my own choice, at my
own expense, and my own liability and assume all responsibility for my use of Viagra. I fully understand that it
is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure
that I have no disease which might make Viagra inappropriate for my condition. I further agree that I have consulted
with my present physician and/or pharmacist and hereby warrant that I am not taking any medications or combination
of medications that are on the published list of medications which would make Viagra contraindicated. CLICK HERE.
I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Viagra
so that they may advise to continue or discontinue use. Should I engage a new doctor's care in the future, I further
agree to immediately notify said doctor of my use of Viagra.
(Viagra). Name
(please print)................................ Signature................................................
Medical Questionnaire
You Must Enter Your Date Of Birth
Date of Birth:
..................................
Telephone number:
..................................
Time
(in your time zone) you prefer to recieive calls related to this prescription:
..................................
Fax number
where information may be transmitted to you from a doctor or pharmacy:
..................................
Email address:
..................................
Address:
......................................................................................................
......................................................................................................
......................................................................................................
Have
you ever had any cardiovascular problems. E.g heart
attack, angina or Stroke (Yes or No)
..................................
Do
you suffer from low blood pressure (Yes or No)
..................................
Known allergies:
......................................................................................................
Medications
(prescription or non prescription/"over the counter") that you are currently taking (even if only occasionally):
......................................................................................................
Do you take any medication classified as a nitrate in
any form?
(Ask your doctor or
pharmacist to check your records).
Yes No
Do you have a problem achieving an erection sufficient
for penetration?
Yes No
Do you have a problem maintaining an erection after penetration?
Yes No
Order form
Please tick the quantity that you require:
Please select the strength of tablet that you require:
50 mg
100 mg
Delivery address
(if different from above):
......................................................................................................
......................................................................................................
......................................................................................................
Have you ordered from Menscare Services before:
Yes No
All Viagra orders on
Menscare Services will be despatched from our pharmacy department in
the UK
All Viagra orders placed before 4:30pm, will get Next Day
delivery before 12:00 midday, Guaranteed.
-Home-
Payment Details
I enclose
my cheque/cash/postal order for £.............. (Cheques payable
to Menscare UK LTD)
Please charge
my credit/debit card account £..............
Card No........................................................................
Expiry Date.......................................
Issue No/Valid from date (If applicable).................................................................................
Name on card............................................Card Company.........................(e.g,
Visa, Mastercard etc)
Signed.................................................................................
| |
Price
|
| Viagra |
£ |
| Total amount due |
£ |
|