Prescription Upload / ORDER YOUR PRESCRIPTION ONLINE . FREE DELIVERY
Our pharmacist will call you soon after verifying your prescription to confirm the order and provide further assistance. Thank you for using our online medicine ordering service.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
*
Delivery Address
*
pincode
*
File Uploader: Please upload your prescription here.
Browse Files
Drag and drop files here
Choose a file
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of
Date Signed
-
Month
-
Day
Year
Date
Signature of Patient / Care taker
FREE DELIVERY
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