Please print out and complete the following form.
These can be either faxed or posted to Menscare Services. 
Click on the button or press 'CTRL' + 'P'
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.


Name (please print)

Signature................................................

 

MEDICAL DECLARATION

Full Name and Title:
Date of Birth (dd/mm/year)  
Height
Weight
Delivery Address
Post code
   
Telephone
Fax


Are you pregnant? Yes No
Are you breast feeding? Yes No
Do you suffer from Jaundice? Yes No
Have you or do you sufferer from anorexia or bulimia ?
 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.
Have you ordered from Menscare Services before? Yes No

ORDER FORM

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

Amounts

Prices

One months supply

 £145.00 sterling
Two months supply £280.00 sterling
Three months supply £415.00 sterling
Four months supply £530.00 sterling
Five months supply £635.00 sterling
Six months supply £730.00 sterling

 

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

Xenical £
Total amount due £

 

Click on the button or press 'CTRL' + 'P'

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

Menscare Services
Menscare, 101 Smithfield Road, Uttoxeter, Staffordshire, ST14 7LD

Telephone : 01889 569467 or 01889 569178
Lines Open - Mon-Fri 8.30a.m to 5.30p.m
Email:admin@menscare.co.uk