All Saints Clinic - Express Order Form

www.allsaintsclinic.org
Secure Express Order and Consultation Form

For Registered Members Only

This secure order form is used for re-ordering medication. Remember, the prices quoted are at least 10% less than our normal prices.

Please carefully complete the form below, fields marked with * are mandatory and MUST be completed. Once completed, click the Submit button at the bottom of this page.

1. Do you require any of the following medications or tests?
Please use the drop down lists to choose your products:

For up-to-date currency exchange rates please take a look at The Universal Currency Converter - this will open a new window (this page will remain open in the background).

ORDER CIALIS:

20mg Pills

ORDER LEVITRA:
WINTER SALE, 16% OFF OUR NORMAL PRICES!

20mg Pills

ORDER UPRIMA:

3mg Pills

ORDER VIAGRA:

100mg Pills

ORDER CAVERJECT 20 mcg PENILE INJECTION:

ORDER ANDRACTIM TESTOSTERONE GEL:

PLEASE NOTE THE FOLLOWING:

* MINIMUM AGE LIMITS: OVER 45 YEARS OF AGE IF ORDERING FOR SEXUAL HEALTH (LOW TESTOSTERONE, MALE MENOPAUSE, ETC). OVER 18 YEARS OF AGE FOR GYNAECOMASTIA TREATMENT. ANY ORDERS FOR ANDRACTIM NOT WITHIN THESE LIMITS WILL MOST LIKELY BE REJECTED.

* MAXIMUM OF 4 TUBES*

* IF THIS IS YOUR FIRST ORDER PLEASE PURCHASE A PSA KIT *

* WE CANNOT SUPPLY ANDRACTIM FOR THE SOLE PURPOSE OF BUILDING MUSCLES *

ORDER PROSTATE CANCER SCREENING (PSA KIT):

2. Delivery Cost

We only charge a per order charge of Ł10 ($16/€14 approx) for postage and packing which is automatically added when you submit your order through to us.

3. Input Name and Address details:

First Name:*

Last Name:*

Postcode/Zip:*

Clinic PIN:*

4. Input Phone, Fax and Email details:

Daytime Phone:*

E-Mail: *

Fax:

5. Input Credit Card Information:

Please note that all credit card transactions may be subject to credit agency checks and may require proof of billing address.

Choose
Card Type: *

Card Number * (please see note below):

Note: When you click on this box, a pop up window should appear on your screen allowing you to put your number in for validation. If this does not happen, do not worry, you probably have an earlier browser or JavaScript disabled.

Security Number (Last 3 Digits):

*
What is this? Click here for details

Exp. Date: *

Make sure you have completed and reviewed the form, and filled in all mandatory fields (*).

PLEASE NOTE: SCROLL MOUSE USERS - RE-CHECK YOUR ORDER FORM! If you have a scroll mouse (a mouse with a wheel or button in the middle that moves the page up and down), please check the details you entered above in the drop down boxes, before clicking the button below. Sometimes the scrolling wheel adjusts the selection in the drop down boxes instead of moving down the page.

TO COMPLETE YOUR ORDER: Please click ONCE on the "Submit" button below to send this form through to us, and wait a few seconds while you are taken to a "Thank you" confirmation page. If you provided us with an email address, a confirmation will also be sent to the email address you specified. Remember that all details are encrypted when sent. The information you give will be held in strict confidence and viewed ONLY by our medical staff.

LIABILITY WAIVER: By clicking the "Submit" button below and submitting this order I hereby simultaneously release All Saints Clinic and all of its employees and contractors, including physicians and pharmacists from any and all responsibility whatsoever associated or connected in any way with any consultation and or my use of the medication so purchased and used.
I hereby confirm that I am an adult and answered truthfully all of the questions asked on the Confidential Health Questionnaire I completed when I registered. Also that, before re-ordering I will inform the clinic of any change in circumstances in matters concerning the aforesaid questionnaire answers previously given.
I hereby confirm that I will carefully read the manufacturer's leaflet supplied with my medication and will strictly adhere to the advice and recommendations therein contained.