Spedra Order Form

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

Spedra 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 Spedra is accepted then it will proceed and be charged to your credit card. In the event that your application to order Spedra 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 Spedra

Do you, or have you ever had cardiovascular problems? *
E.g heart attack, angina or stroke

Yes No

Do you suffer from low blood pressure? *

Yes No

How would you best describe your blood pressure, in general?

Do you take any medication classified as a nitrate in any form? *
(Tablets or Spray) (Ask your doctor or pharmacist to check your records)

Yes No

Do you have a problem achieving an erection sufficient for penetration? *

Yes No

Do you have a problem maintaining an erection after penetration? *

Yes No

Do you have an abnormally shaped penis? *

Yes No

Are you being treated for gastric ulcer or acidity? *

Yes No

Do you have heart, liver or kidney disease? *

Yes No

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.

Would you like us to contact your GP / Doctor to inform him / her of any resultant treatment where applicable?

Yes No

If you choose 'no' you understand it is your responsibility to do so. *
If yes, please provide your GPs details:

Have you ordered from Menscare™ before?

Yes No

Your Spedra order

Please supply me with the following Spedra prescription: * 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 Spedra

I do not have a current prescription for Spedra 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