ED

Full Name

First NameLast Name
Date of Birth

DayMonthYear
Contact Number*
Please provide a valid phone number
Email*
Please select your preferred means of contact from the options below. We need this in case we need to contact you about your order.*

EmailPhone CallWhatsApp
WhatsApp No.*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently registered with a GP?*

YesNo
Please provide the name and address of your GP Surgery*

Practice Name

Street Address

Town/ CityCounty

Post Code

Click on the links below to access the terms and conditions, and the privacy policy. Please ensure that you have read them carefully.

Goodcure Pharmacy Terms and Conditions

Goodcure Pharmacy Privacy Policy
Please tick to agree and confirm all of the following:*

I have understood and agree to the Goodcure Pharmacy's terms and conditions as well as the Privacy PolicyThe treatment is solely for your own use and for the purpose of treating erectile dysfunction.I consent to my details, including IP address, being securely processed and cross-checked by Stripe Radar® for fraud and misuse prevention.I confirm that all the information that I have provided is correct and accurate to the best of my knowledge. I am aware that Goodcure Pharmacy cannot be held responsible for any harm whatsoever resulting from inaccurate information provided my myself.I agree to read the product information leaflet carefully and ensure that I understand it well before using any product or treatment provided by Goodcure. I agree that I will adhere strictly to its guidance.I agree that should I experience any adverse effects resulting from treatment or products obtained from Goodcure Pharmacy, I will discontinue the treatment immediately and seek medical advice as soon as possible.I am aware that Goodcure Pharmacy, in accordance to their professional and moral duty, may report any cases where misuse of treatments or the illegal selling of treatments is suspected.
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