Mail Order Form

Please complete this form as fully as possible.

Please write discount code where applicable in the box opposite
Home Address Title First name Surname Daytime telephone Address Town / City County Postcode Email address Fax	Delivery Address Title First name Surname Daytime telephone Address Town / City County Postcode

If ordering medicines it will help use to make sure you receive the correct preparation by completing the boxes below as fully as possible.

Your Doctor Doctor's name Doctor's Address Town / City County Postcode Travel information Countries visiting Please note: One form must be completed for each user of this product. Please add any relevent information which you may feel is of importance:

Medical Information Any medical conditions Any medication being taken at present time

Please note that if ordering prescription only medicines they must be accompanied by a Private Prescription from your Doctor.

Items Required
Product description & size	Quantity	Unit Price	Total Price
Please send my order by Express Delivery for an additional £6.00
Please send my order by First Class Delivery for an additional £1.00
If your order is under £15.00 please add a handling surcharge of £1.50
Total

Please note that VAT is already included on postage where applicable and there is NO charge for delivery by Royal Mail Second Class Post within the UK.

Payment Details
(Please note we no longer accept cheques) Please tick
Credit / Debit Card
Visa Mastercard Switch Other (please state)
Card Number
Card Valid from / Expiry date /
If switch card, please give issue number
Three or four digit auth number (on the back of card)
Total £
Signature

How did you find us

	Word of mouth
	Repeat order
	Search engine	(please specify)
	Magazine	(please specify)
	Newspaper	(please specify)
	CampsInternational.com
	Homeway Travel with Care
	Winchester Travel Health Clinic
	Surgery Recommendation
	Other	(please specify)

Delivery

No charge for second class delivery within the UK. Orders will leave travelpharm WHEREVER POSSIBLE within 72 hours by first class post (please allow for weekends). All medicines will be despatched by recorded delivery

Returns Policy

If you wish to return items after you have purchased them then please pack carefully and return to TravelPharm. We will issue a refund on receipt. Medicines cannot be returned once they are purchased as they cannot be used or re-issued once they have left TravelPharm. If there is a problem please contact us to discuss it.

Postal Address

Please post the completed form to the following address:

TravelPharm
Manor House
Merlin Way
Ilkeston
DERBYSHIRE
DE7 4RA