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

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

(Procecia). 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 suffer from hair loss ?
 ______
*Do you suffer from any allergies ?
 ______

*Do you have prostate cancer?

 ______
*Have you ever been checked for prostate cancer?
 ______
*ARE YOU TAKING ANY OTHER MEDICATION ?
 ______
PLEASE GIVE DETAILS IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS.
PLEASE LIST ANY MEDICATION YOU ARE CURRENTLY TAKING (PRESCRIBED OR OVER-THE-COUNTER)
 
 
 
 
You must never let a female directly handle the tablets due to the hormonal content.
*I understand Yes
 
If there is a chance of pregnancy, a condom should be worn during intercourse
as propecia can be concentrated in the semen.
*I understand Yes

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

Three months supply £180.00 sterling
Six months supply £340.00 sterling
BEST BUY !
Twelve months supply £600.00 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

Propecia £
Total amount due £

 

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

Menscare Services
Telephone : 01889 569467 or 01889 569178
Lines Open - Mon-Fri 8.30a.m to 5.30p.m
Email:Admin@menscareworldwide.com