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 Xenical Consultation and/or my use of Xenical. I hereby state that I am an adult and that I am aware of the potential side effects associated with Xenical. 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 Xenical, even if prescribed, will provide the results I seek. Further, I understand that even if prescribed, I may suffer adverse effects from Xenical. 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 Xenical.
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 Xenical. 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 Xenical 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 Xenical contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Xenical 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 Xenical.
(Xenical). Name (please print)................................ Signature................................................
TOTAL DISCRETION IS ASSURED - YOUR MEDICAL DETAILS WILL NEVER BE PASSED ON TO A THIRD PARTY
Please tick the quantity that you require:
Amounts
Prices
One months supply
Delivery address (if different from above): ...................................................................................................... ...................................................................................................... ......................................................................................................
Have you ordered from Menscare Services before: Yes No
Price
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