Regaine Order Form

The Regaine order page is located on a secure server to guarantee complete confidentiality and security.

Regaine is a prescription medicine. So that we can quickly process your order you will need to complete the following medical application form, answering all questions completely, truthfully and accurately.

If your application to order Regaine is accepted then it will proceed and be charged to your credit card. In the event that your application to order Regaine is not accepted, then there will be no charge.

Please fill in all sections marked with (*).

Personal Details

Full Name *

Gender (is not suitable for females)

Date of Birth (dd/mm/year) *

Delivery Address *

Medical questions for Regaine

Have you used Regaine (minoxidil) before? *

Yes No

I understand that women should not use Regaine Extra Strength (5% minoxidil).

Yes

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™ before?

Yes No

Your Regaine order

Please supply me with the following Regaine Extra Strength: * All prices include delivery within 24 hrs (UK)

Promo Code

Agreement

By submitting this application form:

Agree

I certify that I am 18+ years of age

I take full responsibility of informing my Doctor of this medication.

I have read and understand the potential side-effects of Regaine

I do not have a current prescription for Regaine from another source.

I certify that I am allowed by law to use the credit card used to place this order.

I accept full responsibility for my use of the supplied drugs.

I certify that I have answered all the questions truthfully.

Terms and Waiver of Liability

Do you agree to our Terms and Waiver of Liability? *
Please read our Waiver of Liability conditions.

I agree

GDPR Compliant Privacy Policy

Do you agree to the GDPR Compliant Privacy Policy? *
Before we can process your order we need to confirm your agreement,
[Please click here to fill in the form] if you have not already done so.
Please read the GDPR Compliant Privacy Policy.

I have already agreed

Receipt

Would you like a receipt for your order?

Yes No

Payment Information

Please enter your payment information below

Name on card *

Email Address *

Card Holder Address if different to Delivery Address *

Telephone *

Card Number *

Expiry Date *

Valid From

Issue No. *

CVV2 Number 3 Digit Code