PLACE AN ORDER

PLACE AN ORDER



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Maximum file size: 8MB

Maximum file size: 7MB

IF “NOT CALLED” – WE HAVE RECEIVED SCRIPT RECENTLY BUT WE HAVE NOT CALLED THEM WITH A PRICE. IF “CALLED/NO ANSWER” – WE HAVE TRIED TO CALL THE CUSTOMER AND ARE AWAITING THEM TO CALL BACK
ALWAYS ask everyone these questions even if they have told us before as they may have new medications/conditions
IF CUSTOMER DOESN’T WANT THE CC DETAILS TO BE KEPT ON FILE – PLEASE PUT CREDIT CARD DETAILS AT THE BOTTOM OF FORM

Items to make

Click ADD to add another premade
Has this customer had this medication before?
SCRIPT DETAILS
ie. Progesterone 4% cream 100gm
$
$
$
Add Remove
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One off Credit Card for pickup
One off Credit Card for pickup
Card Number
Year
CVC
Month
Any changes to regular script- Notes to dispenser- I.E. No sweetener etc
Shipping Insurance required?
Add any special notes for postage
Please select the correct Shipping Insurance fee according to the Shipping Value
Invoice required?

Collection/Postage Information

IF EARLY PICKUP TIME PLEASE PUT THE TIME THEY WANT TO COLLECT

Other Information

Payment Details ( for once off payments)

ONLY SELECT CREDIT CARD IF THIS IS A ONCE OFF PAYMENT AND THEY DON’T WANT TO KEEP THE DETAILS ON FILE

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