Prescription Order Form

Personal Details
Ttile*
Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Weight (kg)*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Delivery Address*
- Same as above
- Different from home address
Address*
Street Address City State Post Code
Home Phone
Mobile Phone*
Email*
Payment Details
We accept VISA and Mastercard only. You can also pay via EFT. Please provide a valid contact number and email above so that we may contact you to arrange payment.
Payment Type*
NB: If you cannot locate the exact product (ingredients, strength and qty) please use the call back option below.
Delivery Details
It may take up to 2 working days to make your compound then a further 1-2 days for nationwide delivery. Upon receipt of your order we will contact you directly to advise you of expected delivery date.
Preferred delivery method*
NB: Courier option not available for PO Box addresses or security buildings without concierge.
Special delivery instructions
Order Details
Current Practitioner
Product(s) Ordered | Quantity
Upload Prescription
File
Accepted file types: jpg, jpeg, jpg, gif, png, doc, pdf.
File Size: 2000KB Maximum
Name
This field is for validation purposes and should be left unchanged.

Personal Details