SAME DAY DESPATCH FROM OUR BRITISH PHARMACY BEFORE 1PM (NOT INCLUDING HOLIDAYS/WEEKENDS)
ED MEDICAL DECLARATION
PLEASE COMPLETE THIS FORM FOR ALL ED DRUG REQUESTS - YOU WILL THEN BE ABLE TO REQUEST YOUR DRUGS AND COMPLETE YOUR ORDER
Please complete all the following fields;
Fields in RED and marked * are mandatory and MUST be completed.
PLEASE NOTE that this form must contain the details of the person who will be using the treatment.
* House Name or number
* Post Code/ZIP
Your Date of Birth.
What sex are you? (YOUR GENDER - MALE or FEMALE)
Do you suffer from erectile dysfunction (impotence)?
ED drugs can only be supplied if you suffer from impotence (the condition may be temporary or permanent)
Do you suffer from Angina?
Do you suffer from any Kindey or Liver disease?
Do you have any serious visual problems?
Do you suffer from active Duodenal or Stomach ulcers?
Do you suffer from Sickle Cell Anaemia, Leukaemia or Multiple Myeloma?
Do you suffer from High Blood Pressure?
Do you receive any treatment for Heart Problems?
If yes, please enter details in comments field below
Do you suffer from any Abnormality of the Penis?
If yes, please enter details in comments field below.
Men who have an abnomally shaped penis such as Angulation, or who suffer from Cavernosa Fibrosis or Peyronies Disease may not be able to take ED drugs. If in any doubt to any of the above conditions consult your Doctor
At your next medical consultation, please remember to tell your doctor that you are taking an ED treatment.
Are you taking any of the following medication; Ketoconazole, Ritonavir, Atazanavir, Clarithromycin, Indinavir, Itraconazole, Nefazodone, Nelfinavir, Saquinavir or Telithromycin?
Are you taking any other medication (either over-the counter or prescription)
Please list all medications that you are taking (including those not requiring a prescription) in the comments field below.
Do you have any known allergies?
If the answer is yes, please enter details in the comments field below.
Is there any reason why you believe you may not be able to take ED treatments?
DRM advise you to discuss any concerns about this questionnaire or the use of ED drugs with your own Doctor.
Have you been prescribed an ED drug (Viagra, Cialis, Levitra etc) before?
(Any previous prescription, either from your own doctor or from another supplier)
Check this box if you would like the doctor to contact you about your condition.
you can also contact our doctor for more advice at any time by using this link Email Doctor
Comments; Please use this field to add details or to expand further on the above questions if necessary, or to tell us more about your problem so that our doctor can help you further.
Please enter any surgical history.
Standard medical practice requires your General Practitioner / Doctor to be aware of any medication prescribed to you.
I take responsibility for informing my G.P. / Doctor
If you have selected "NO", you must enter your doctors name and address below, so that DRM can inform them.
I confirm that I have read and understood the information given and that the above information is the truth to my certain knowledge.
I know of no reason why I should not be prescribed this product and I take full responsibility for my use of the product as recommended by the manufacturers.
I believe that this consultation by the DRM appointed doctor is in my best interest as a patient and I consent to my medical and payment data being processed by DRM and being made available to the DRM appointed Doctor(s) and/or Pharmacy.
I have read and understood the product information given regarding the use of this product by both DRM and the manufacturer, and I will read the packaging and enclosed leaflet before use.
For more information read our privacy page
By typing your name here you confirm your acceptance of the above statements
Daytime Telephone Number*
Have you ordered via drm before?
(This will help us to process your order more efficiently)
TOTAL DISCRETION IS ASSURED - YOUR DETAILS WILL
NEVER BE PASSED ON TO A THIRD PARTY
Please press the button below only once and wait for the confirmation.
If you made a mistake when ordering, please contact us immediately preferably by phone or email.
UK law forbids the pharmacy from accepting back any prescribed medications once despatched.
This is a secure online form that uses server encryption to protect your personal data.
CURRENCIES? -- orders will be applied to your credit card in U.K. Pounds,
the amount will automatically be debited in your own currency, at the rate
prevailing on the day of transaction by the credit card company.
Goods are despatched tax-free in the EU, but DRM cannot be responsible for local taxes or import restrictions which may apply in other countries.
Your order will normally be despatched on the day of your order if we received it before 1P.M (not weekends or holidays).
Orders to the UK should arrive within 48 hours. Please allow 7 working days to Europe, 15 working days to OTHER COUNTRIES.
YOUR GUARANTEE! - If your goods do not arrive for any reason, DRM will re-ship or refund your order!
Direct Response Marketing (Jersey) Limited.
Suite 15 Burlington House, St Saviours Road, St Helier, Jersey, British Channel Islands. JE2 4LA
Telephone; 0845 121 6667 (UK local rate)
Fax; 0845 121 6669 (UK local rate)
International Telephone (44) 1534 510271
General Enquiries - email: Email DRM: Order Enquiries - email: Email order dept All trademarks are acknowledged as the property of their respective owners.