The Minoxidil Club
MINOXIDIL and FINASTERIDE VALUED CUSTOMER ORDER FORMDear Customer,
Our new Valued Customer Priority Order Form will make it even easier to order your products.
Please complete the order form when you need to re-order, then attach your payment and send it off.
If you are ordering Finasteride, you must also fill in the Medical Questionnaire printed overleaf.
Please supply the products as detailed below. Postage is FREE to the U.K and Northern Ireland.
I agree to the Terms and Conditions of sale, which may be viewed on the Minoxidil Club website.
MEMBERSHIP NUMBER
/......
NAME / ......DELIVERY ADDRESS / ......
......
......
POSTCODE / ......
CONTACT PHONE NUMBER / ......
E-MAIL ADDRESS / ......
PLEASE CHECK THE LATEST PRICES ON THE MINOXIDIL CLUB WEBSITE ORDERS PAGES
and
Our new web sites are: and
CODE / DESCRIPTION / PRICE / QUANTITY / TOTAL
A / REGAINE 5% Minoxidil Lotion 90 day supply / £ 595.99 / Currently out of stock / £
AA / KIRKLAND 5% GENERIC Minoxidil Lotion 90 day supply / £44.99 / £
B / PROSCAR Finasteride 5mg. Tablets 30 day supply / £ 34.99 / £
C / PROSCAR Finasteride 5mg. Tablets 90 day supply / £ 89.45 / £
D / PROSCAR Finasteride + REGAINE Minoxidil Lotion 90 day supply / £ 1452.99 / Currently out of stock / £
DD / PROSCAR Finasteride + KIRKLAND GENERIC Minoxidil 90 day supply / £ 119.99 / £
END TOTAL / £
PLEASE SIGN HERE TO CONFIRM YOUR ORDER
- Don’t forget to write your cheque guarantee number and the expiry date of your cheque card on the back of your cheque. Please remember to include TWO cheques if your payment exceeds your cheque card guarantee value. (Normally £100.00)
SORRY BUT WE CANNOT PROCESS YOUR ORDER WITHOUT THIS...
- Please make your cheque payable to THE MINOXIDIL CLUB and send it to us at the mailing address below... Super-fast despatch is 100% guaranteed with our Priority Order Form.
The Minoxidil Club, 15 South Street, South Chailey, East Sussex, BN8 4BB
The Minoxidil Club
FINASTERIDE MEDICAL QUESTIONNAIREDear Customer,
Thank you for your interest in ordering your hair regrowth treatment from The Minoxidil Club. Finasteride is normally only available on doctor’s private prescription in the U.K and is extremely expensive. Therefore, our customers currently purchase their Finasteride from outside the U.K in the form of PROSCAR 5mg. tablets. We have negotiated a substantial discount with a reputable hair loss clinic and will simply forward your orders for dispensing.
In order to fully comply with The Medicines Act 1968, each individual order will be reviewed separately and returned to us only for repacking and posting.
Your Finasteride will be individually prescribed in the form of PROSCAR tablets, by a registered doctor practicing outside the U.K. For this reason, you will need to complete a short Medical Questionnaire each time you purchase your Finasteride. This is legal and ethical practice and ensures that your prescribing details are always up to date.
Before we pass on your order, you must inform your own doctor that you intend to use Finasteride 1mg. per day for the treatment of male pattern hair loss.
We insist that you must not begin a course of treatment unless your doctor fully approves.
PLEASE ANSWER ALL QUESTIONS...
Are you Male ? / YES / NO
Are you between the ages of 18 and 50 ? / YES / NO
Do you suffer from male pattern hair loss ? / YES / NO
Are you allergic to any medications ? / YES / NO
Have you ever been refused Finasteride on medical grounds ? / YES / NO
Have you ever been diagnosed with prostate cancer ? / YES / NO
Do you suffer from liver disease ? / YES / NO
Are you taking any other medication ? (including non-prescription) / YES / NO
Are you trying to conceive a child or will you be trying in the next 3 months ? / YES / NO
Do you agree to inform your G.P before taking Finasteride tablets ? / YES / NO
YOUR STATEMENT...
I confirm that I have read and understood the contents of this form and that the above information is truthful and accurate to my certain knowledge. I understand that women should not handle the tablets (especially if broken or damaged) and that I should wear a condom during intercourse if there is any risk of pregnancy as Finasteride may be concentrated in the semen. I accept full responsibility for informing my G.P and for my use of the supplied medication and indemnify The Minoxidil Club and it's associates from any unintended effects resulting from my use of Finasteride.
Signing this form signifies acceptance of the above statements.
Your signature...
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