pharmcom

Welcome to Pharmcom by Mail Order.

With this page you can place an order for Propecia and send it to Pharmcom by post or fax. You can make payment by credit card or you can send your order by post and include an international money order or a cashiers check.

To place an order, please fill in your details below, print out this page and post it to:

Pharmcom International
P.O.Box 100-169
North Shore Mail Center
Auckland 1310
New Zealand

Alternatively you can fax your order to Pharmcom on ++ 649 479 1083 . If you are faxing from the United States, please replace the '++' with 011.



	First name(s):

	Surname:

	Address:

	City:

	State/Region:

	Postcode:

	Country:

	Email:


	Age:

	Weight:

	Height:

	Tel (inc area code):

	Fax (inc area code):

	Sex:	Male Female

	Do you suffer from male pattern hair loss?	No Yes

	Do you plan to take a PSA blood test for the screening of prostate cancer? Propecia can affect a blood test called PSA (Prostate-Specific Antigen) for the screening of prostate cancer. It is very important that you advise the doctor you are taking Propecia if you have a PSA test done.	No Yes

	Do you suffer from any form of liver disease?	No Yes

	Known Allergies:

	Current Medications: Please list all prescription and non-prescription ("over the counter") medications you are currently taking, even if only occasionally.

	Do you have any medical conditions. If so please give details. If you are unsure, you should ask your regular doctor.

	Do you consider anything else in your medical history to be relevant. Please give details

	Select Quantity:

	Select method of payment:

	Credit card number:
	Expiration date:

	Delivery instructions (if any):


home \| privacy statement \| testimonials \| about us \| information \| online store