Anaesthetic Cream/Gel Order Form


Order Form

Please ensure you complete this form with YOUR details (The Person who will be using the product), Once completed our staff will be in contact to organise payment and to confirm pick up or delivery of your order

Pickup or Delivery?
I confirm:
I confirm:
I confirm:
Product Required
Type of Numbing required

Pre-treatment Numbing

During Treatment Numbing

Do you have a prescription for this item?

Maximum file size: 60MB

Quantity Required (Price will be advised)
Have you use a topical Anaesthetic before?
IMPORTANT: A Patch test should be performed at least 24 hours before use- Apply a small amount to the inside of the arm and leave on for 20 minutes- If no skin reaction (Redness/Itching/Swelling/Stinging) then it should be safe to use.