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 All major Credit Cards accepted
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SAME DAY DESPATCH FROM OUR BRITISH PHARMACY BEFORE 1PM (NOT INCLUDING HOLIDAYS/WEEKENDS)
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Product information

If you have any problems, please Email DRM to let us know.
This is a secure online order form that uses server encryption to protect your personal data.

HAIR LOSS

MEDICAL DECLARATION

PLEASE COMPLETE THIS FORM FOR ALL HAIR LOSS TREATMENTS - YOU WILL THEN BE ABLE TO REQUEST YOUR DRUGS AND COMPLETE YOUR ORDER

Please complete all of the following fields;
    Title (Mr,Mrs,)

    First Name

    *

    Family Name

    *

    Date Of Birth.

    *

    Please confirm your GENDER (SEX);
    *
    Your Address
    House Name or number
    Town/City
    Post Code/ZIP
    Country
    *

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

    Do you suffer from hair loss ?

*

    *Do you suffer from any allergies ?
    If yes, please enter details in comments area below

*

    Have you ever been checked for (or diagnosed with) prostate cancer?
    If yes, please enter details in comments area below

*

    Have you ever been checked for (or diagnosed with) liver problems?
    If yes, please enter details in comments area below

*

    Have you been prescribed Propecia or Avodart before ?
    (Any previous prescription, either from your own doctor or from another supplier)

*

    Have you used Minoxidil before ?
    (Any previous product i.e. Regaine or aother Mixidil Foam or solution.)

*

    Are you taking any other medication (including non-prescription)?
    If yes, please enter details in comments area below

*
    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
    YES, I would like the doctor to contact me.
    (Please enter details below.)
    Please enter any comments in this space.

    Is there any reason why you believe you may not be able to take this drug?

*
    I understand that women should not handle the tablets (especially if broken or damaged) and that I should wear a condom during intercourse if there is any risk of pregnancy (Propecia / Avodart may be concentrated in the semen). 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

      SIGNED*
      Please type your name here to signify your acceptance of the above statements.
    Please enter your contact details here, so that we can acknowledge your order

    Email
    *

    Daytime Telephone Number
    *

    Have you ordered any product from drm before?
    *

You already know that DRM never share our customer's details with any other company or organisation.
Neither do we send out regular emails purely for marketing purposes, but we are required to send you an email to follow up on your treatment. We may very occasionally, send our customers updated information regarding a product, or when a new treatment becomes available.
If you do not wish to receive these emails, please indicate by clicking this box;

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 page.

PLEASE NOTE; - Once your order is placed we may not be able to cancel or change it.
If you make 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 order form that uses server encryption to protect your personal data.


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Read our Privacy Statement and Customer Guarantee

ALL PRICES ARE IN U.K POUNDS STERLING (£)

The price includes;- your consultation fee !
OTHER 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.

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