Order Medication

You can request your medication by filling the form below. Please give us at least 2 days for your prescription to be ready.

Medication request Form

* Your Name:

* Your Phone Number:

Your Email

* Date of Birth

* Please say if you want to collect by yourself or your pharmacist will collect it I will collect it personally My Pharmacist

Your Pharmacy Name & Address

When will you collect the script

* Write each medicine in each Row clearly. Check spellings and doses

* Type the numbers.