PRESCRIPTION REQUEST
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
-
Day
-
Month
Year
Date
Year
Email
*
example@example.com
Phone Number
*
-
Medications requested
*
Collection Method
*
Collect from Chosen Pharmacy
Home delivery - FREE *Additional surcharge(s) will apply for less than 4 medications, non subsidised items and rural delivery.
Pharmacy Details
*
Home delivery - free if 4+ items
*
Pharmacy Now (same day delivery if ordered before 12pm)
Are you a Southern Cross Easy Claim member?
*
Yes
No
Secure Stripe Payment
*
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Prescription
$25.00 NZD
$
25.00
NZD
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Please verify that you are human
*
Submit
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