48 HOUR DELIVERY - ALL PRESCRIPTION PRODUCTS - UK MAINLAND (NOT INCLUDING HOLIDAYS/WEEKENDS)

CIALIS SPECIAL OFFER - MEDICAL DECLARATION

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.
Title (Mr, Dr, )
First Name	*
Family Name	*
Your Height	*
Your Weight	*
Your Date of Birth.	*
What sex are you? (YOUR GENDER - MALE or FEMALE)	*
Do you suffer from erectile dysfunction (impotence)? Cialis 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 active Duodenal or Stomach ulcers??	*
Do you suffer from Sickle Cell Anaemia?	*
Do you suffer from Leukaemia?	*
Do you suffer from 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 Cialis. If in any doubt to any of the above conditions consult your Doctor	*
Are you taking any medication which would prevent you from being prescribed Cialis? (Cialis must NEVER be taken in combination with NITRATE-based drugs including Amyl-Nitrates.) Click here for list of nitrate-based meds. At your next medical consultation, please remember to tell your doctor that you are taking Cialis.	*
Are you taking any 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 Cialis? DRM advise you to discuss any concerns about this questionnaire or the use of Cialis with your own Doctor.	*
Have you been prescribed Cialis 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
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 details of any medical conditions or medications taken (prescribed or over-the-counter) here.
Please enter any surgical history. Please enter details of any surgery here.
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.
Please enter your doctors name and address here, if you have chosen not to inform them yourself.
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 data being made available to the DRM appointed Doctor and 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. Full Name;-* By typing your name here you confirm your acceptance of the above statements

TOTAL DISCRETION IS ASSURED - YOUR DETAILS WILL NEVER BE PASSED ON TO A THIRD PARTY

ORDER FORM

CIALIS

Despatch Address

NOTE; If your credit card billing address is not the same as the despatch address, please enter it in the "commments" field

County / Area

Country

Zip / Post Code

Fax Number

Daytime Telephone Number

PLEASE SUPPLY;-

Exchange? £=$
Personal Currency Assistant

PLEASE SELECT THE QUANTITY;

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

*OFFER EXTENDED ONLY WHILE STOCKS LAST AT THIS PRICE!
DRM reserve the right to discontinue this promotion without notice.
Please note - offer does NOT apply to quantity 4

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.

Please debit my credit card.

Please enter 'XXXX' if any field is left blank after entering your number

We accept Visa, Mastercard, Switch and Connect cards.

Expiry date of card

Switch issue number (if applicable)

Credit Card Security ID number (This is now mandatory):

Please note that in an effort to reduce fraud and to safeguard the customer it is now necessary to supply the Security ID for Credit Card transactions. If your card does not have a Security ID or you are unable to read it, please contact us. Click the link below for an image of the location of the Security ID on your card.
Visa/Mastercard - Security ID is printed on the signature strip on the back of the card.

Name (as it appears on card)

Please acknowledge;-

I am aware that my order will be charged in £ (GB Pounds sterling) and that if I am ordering from outside the UK then the exchange rate will be determined on the day of transaction

Please enter your name and email address here, so that we can acknowledge your order

Name

Email*

Have you ordered via drm before?

(This will help us to process your order more efficiently)

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 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;

Please check that you have answered ALL the questions.

Some browsers will not retain the form data and you may need to complete the form again.

The order may take a few moments to process.

Please press the button below only once and wait for the acknowledgement page. Thanks.

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

Concerned about ordering online?

About secure ordering online

Read our customer feedback

Read our Privacy Statement and Customer Guarantee

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

The price includes;- your prescription fee PLUS postage and packing to ANY country !

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 rest of the world.

YOUR GUARANTEE! - If your goods do not arrive for any reason, DRM will re-ship or refund your order!

Direct Response Marketing Limited.

38 Apsley Road,

St Helier,

Jersey. Channel Islands.

JE2 3LR.

Telephone; 0845 121 6667 (UK local rate)

Fax; 0845 121 6669 (UK local rate)

International Telephone (44) 1534 510271

International Fax (44) 1534 510272

General Enquiries - email: email us
Order Enquiries - email: Email order dept

XENICAL is the trademark of F. Hoffmann-La Roche Ltd

Propecia is the trademark of Merck & Co., Inc.

Viagra is the registered trademark of Pfizer Inc. NY.

Zyban is the registered trademark of Glaxo Wellcome, USA.

Cialis is the registered trademark of Eli Lilly and Company.

General Enquiries - email: email us

Order Enquiries - email: Email order dept

VIAGRA : XENICAL : PROPECIA : AVODART : CIALIS : LEVITRA : ORDER REGAINE (Minoxidil) :
PRODUCT INFORMATION : OTHER PRODUCTS? : LOST? - SITE MAP : LINKS : DRM HOME

Direct Response Marketing Limited.

38 Apsley Rd, St Helier, Jersey, British Channel Islands. JE2 3LR.
Telephone; 0845 121 6667 (UK local rate)
Fax; 0845 121 6669 (UK local rate)
International Telephone (44) 1534 510271

General Enquiries - email: email us: Order Enquiries - email: Email order dept
All trademarks are acknowledged as the property of their respective owners.

213.210.51.21