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CLICK HERE to go to the secure online order form
( This is the PRINTABLE version )

 

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 Services
101 Smithfield Road, Uttoxeter, Staffordshire, ST14 7LD, England.

By mail:
Print out the order form and post it with your payment to:
Menscare Services
101 Smithfield Road, Uttoxeter, Staffordshire, ST14 7LD, England.

Make your cheques or postal orders payable to: J.P.G Associates

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 Levitra Consultation and/or my use of Levitra. I hereby state that I am an adult and that I am aware of the potential side effects associated with Levitra. 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 Levitra, even if prescribed, will provide the results I seek. Further, I understand that even if prescribed, I may suffer adverse effects from Levitra. 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 Levitra.

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 Levitra. 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 Levitra 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 Levitra contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Levitra 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 Levitra.

(Levitra). Name (please print)................................ Signature................................................

MEDICAL DECLARATION

Do you suffer from any of the following (or any associated condition)?
please write YES or NO clearly in the space provided for ALL questions.
Do you, or have you ever had cardiovascular problems ? *
E.g heart attack, angina or stroke
 Yes No
Do you suffer from low blood pressure ? *
 Yes No
Do you take any medication classified as a nitrate in any form? *
(Tablets or Spray) (Ask your doctor or pharmicist 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
Do you have an abnormally shaped penis ? * Yes No
Are you being treated for gastric ulcer or acidity ? * Yes No
Do you have heart, liver or kidney disease ? * Yes No

Do you suffer from any allergies ? * Yes No
If yes state in box.  
Are you taking any other medication? * Yes No
If yes state in box.

TOTAL DISCRETION IS ASSURED - YOUR MEDICAL DETAILS WILL NEVER BE PASSED ON TO A THIRD PARTY

Order form

All prices shown on this website are inclusive and include special delivery charges
Please tick the quantity that you require:

Amounts

Prices

4 Pills (10mg) £70.00 sterling
8 Pills (10mg) £130.00 sterling
12 Pills (10mg) £190.00 sterling
16 Pills (10mg) £245.00 sterling
24 Pills (10mg) £336.00 sterling
32 Pills (10mg) £432.00 sterling
64 Pills (10mg) £750.00 sterling
BEST BUY !
96 Pills (10mg) £1050.00 sterling


Amounts

Prices

4 Pills (20mg) £80.00 sterling
8 Pills (20mg) £150.00 sterling
12 Pills (20mg) £210.00 sterling
16 Pills (20mg) £275.00 sterling
24 Pills (20mg) £400.00 sterling
32 Pills (20mg) £480.00 sterling
64 Pills (20mg) £850.00 sterling
BEST BUY !
96 Pills (20mg) £1200.00 sterling

Delivery address (if different from above):
......................................................................................................
......................................................................................................
......................................................................................................

Have you ordered from Menscare Services before: Yes  No

 

                                                    Payment Details

 I enclose my cheque/cash/postal order for £.............. (Cheques payable to J.P.G Associates)
 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

Levitra £
Total amount due £

 

All Medicines dispatched from our UK Pharmacy
Guaranteed Next Day Delivery included

Menscare Services
Telephone: 01889 569467 or 01889 569178 Fax: 01889 562036
EMAIL: Admin@menscareworldwide.com