Tamiflu Order

Personal Details

Full Name *

Gender

Date of Birth (dd/mm/year) *

Delivery Address *

Medical questions for Tamiflu

When was your last full check up with your regular GP (general practitioner)?

Have you been prescribed with this medication (Tamiflu) before?

Yes No

Are you currently suffering from any of the flu symptoms?

Yes No

Do you wish to have this medication as a precautionary measure in case of contact with people with the flu? (You must be aware not to take this medicine unless you feel the symptoms of the flu)

Yes No

Do you understand that only one medication should be taken as a treatment for the same condition at any one time and should the initial treatment not work you will contact a doctor before proceeding with the second?

Yes No

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

Do you suffer from any form of renal impairment?

Yes No

Do you have/have you had cardiovascular problems?

Yes No

Are you pregnant?

Yes No

Are you breastfeeding?

Yes No

Is there a history of disorders in your family (medical or otherwise)?

Yes No

Do you suffer from asthma?

Yes No

Do you have/have you had respiratory problems?

Yes No

Do you use any form of inhalers?

Yes No

If yes please advise us which inhalers in box below.

Are you taking any other medication?

Yes No

Please include both prescription medication and OTC medicines e.g. St. John's wort

Is there anything else which you feel we should know about regarding your medical condition and request for treatment? (e.g. any major surgeries, physical abnormalities, general medical problems not covered above)

Yes No

If yes state in box.

It is in your best interests if a doctor who prescribes for you can share information with your regular GP, e.g. by telling him or her what has been prescribed for you. If you agree that the prescriber can share information with your GP, please signify your consent by filling in his/her name and address here. (optional) ?

Have you ordered from Menscare™ before?

Yes No

Your Tamiflu order

Please supply me with the following Viagra 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 Tamiflu

I do not have a current prescription for Tamiflu 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

Tamiflu Order Form

Personal Details

Medical questions for Tamiflu

Your Tamiflu order

Agreement

Terms and Waiver of Liability

GDPR Compliant Privacy Policy

Receipt

Payment Information