Please Note: This form is to be used by an operator who can physically issue you with a Pelvipro.
We can not deliver a Pelvipro via this form.

Retailer Rentals

This amount is taken now from your card.
Automatically taken 45 days after your product issue date, only if you wish to purchase.

Stopping the payment is easy:

(You can tick more than one box if appropriate.)
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