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Please fill in all sections marked with (*).
 

 

Personal Details
Full Name *
Delivery Address *
Date of Birth (dd/mm/year) *
Gender (is not suitable for females)
   

Medical questions for LEVITRA
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
Do you take any medication classified as a nitrate in any form? *
(Tablets or Spray) (Ask your doctor or pharmicist 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.
Have you ordered from Love Pharmacy before? Yes No


Your LEVITRA order
Please supply me with the following LEVITRA prescription: *
Please note that it is prohibited to accept returns of prescription medication. We therefore cannot accept returns or refunds.


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 Levitra.
I do not have a current prescription for Levitra 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


Please enter your payment information below



Payment information
Name on card *
Email Address *
Card Holder Address*
(if different to Delivery Address)

Telephone *
Card Number *
(numbers only, no dashes or spaces)
Expiry Date *  
Valid From:
Issue No: if using Switch or Solo
CVV2 Number: (3 Digit Code)



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