I hereby release Menscare Services and all of its employees and contractors including physicians from any and all liability whatsoever associated or connected with my Viacreme Consultation and/or my use of Viacreme. I hereby state that I am an adult and that I am aware of the potential side effects associated with Viacreme. I hereby agree to answer truthfully all of the medical questions on my questionnaire.

I understand that no doctor, nurse, or administrative personnel can guarantee that Viacreme, even if prescribed, will provide the results I seek. Further, I understand that even if prescribed, I may suffer adverse effects from Viacreme. I hereby release Menscare Services and all of its employees and contractors including physicians from any and all liability whatsoever associated with any adverse effects I may suffer from my use of Viacreme.

I am submitting this questionnaire at my own choice, at my own expense, and my own liability and assume all responsibility for my use of Viacreme. I fully understand that it is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that I have no disease which might make Viacreme inappropriate for my condition. I further agree that I have consulted with my present physician and/or pharmacist and hereby warrant that I am not taking any medications or combination of medications that are on the published list of medications which would make Viacreme contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Viacreme so that they may advise to continue or discontinue use. Should I engage a new doctor's care in the future, I further agree to immediately notify said doctor of my use of Viacreme.

CONTINUE TO MEDICAL FORM

Menscare Services
101 Smithfield Road, Uttoxeter, Staffordshire, ST14 7LD, England.
Telephone: 01889 569467 or 01889 569178 Fax: 01889 562036
Email:admin@menscare.co.uk