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

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

(Viacreme). Name (please print)................................ Signature................................................

 


Order form

Please tick the quantity that you require:

Amounts

Prices

Two Sachets

 £20.00 sterling
Four Sachets £35.00 sterling
Six Sachets £50.00 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

Viacreme £
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

 

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