Printable Order Form

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 UK LTD. 57 Balance Street, UTTOXETER, Staffordshire, ST14 8JQ.

By mail:
Print out the order form and post it with your payment to:
Menscare UK LTD. 57 Balance Street, UTTOXETER, Staffordshire, ST14 8JQ.

Make your cheques or postal orders payable to: Menscare UK LTD

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

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

(Muse). Name (please print)................................ Signature................................................

MEDICAL DECLARATION

TITLE .............FIRST NAME(S) ........................................... FAMILY NAME ...........................................

* Date Of Birth. .......... / .......... /.......... EMAIL .....................................................

* Your Gender....................( Male / Female )

*ADDRESS ........................................................................................................

........................................................................ POST / ZIP CODE ..........................

*TEL.NO .................................................. FAX ........................................................

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 have any blood disorders ?
______

*Do you have unstable angina ?
______

*Do you have a history of stroke ?
______

*Do you suffer from any allergies ?
______

*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)

If there is a chance of pregnancy, a condom should be worn during intercourse
as muse 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
Pack of Six / 500 mcg	£150.00 sterling
Pack of Six / 1000 mcg	£150.00 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 Menscare UK LTD)
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
Muse	£
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@menscare.co.uk

*Do you have any blood disorders ?	______
*Do you have unstable angina ?	______
*Do you have a history of stroke ?	______
*Do you suffer from any allergies ?	______
*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)

If there is a chance of pregnancy, a condom should be worn during intercourse as muse can be concentrated in the semen.
*I understand Yes****