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
*
prev
next
( X )
Prescription
$
25.00
NZD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please verify that you are human
*
Submit
Should be Empty: