PLEASE COMPLETE THIS FORM AND SEND IT WITH YOUR
MEDICAL ASSESSMENT FORM AND PAYMENT TO THE ADDRESS INDICATED

Please complete the following information: We will be using this information to send your order so please make sure it is correct.

Please ensure the name, address and postcode you enter exactly matches that on the card you are using for payment. We are unable to send to a different address without prior telephone agreement.
Surname: Forename:
Address: Postcode:
Telephone: Email:
YOUR ORDER DETAILS
Just enter the number of packs you need and press the 'calculate' to work out how much to send.button
Pack description No of packs Price per pack Order value
4 Viagra 25 mg @ £30.00 £30.00 =
4 Viagra 50 mg @ £34.00

£34.00 =
4 Viagra 100 mg @ £40.00 £40.00 =
4 Levitra 10 mg @ £40.00 £40.00 =
4 Levitra 20 mg @ £40.00 £40.00 =
4 Cialis 10 mg @ £40.00 £40.00 =
4 Cialis 20 mg @ £40.00

£40.00 =
Pill cutter @£2.50 £2.50  =
Postage & Packing (uk only) £
OR SAVE £15.00 WITH OUR SPECIAL COMBINATIONS.
24 Viagra 100 mg, Prescription fee, Pill cutter, Postage & Packing. Only £205.00 X£205.00 =
24 Levitra® 20 mg, Prescription fee, Pill cutter, Postage & Packing. Only £205.00 X£205.00 =
24 Cialis® 20 mg, Prescription fee, Pill cutter, Postage & Packing. Only £205.00 X£205.00 =
Please provide your payment details:
Cheque enclosed Value:
Credit /debit card type:
Card no: Issue No:  (switch & maestro only)
Security Code  
Expires end:
 Start Date: (switch & maestro only)
Now print out the form and sign below:

Signature

Post the completed and signed form to The Potency Clinic (address below) together with your remittance and prescription,or medical assessment form.
Please make cheques payable to v.jairath

I am enclosing/forwarding a prescription
I have completed the medical assessment form

The Potency Clinic,
 RVS Healthcare Ltd
356-358 Worsley Road
Winton
M30 8JA