Booking Form with Calendar

1

Is this script for a current/chronic condition, or something new?* This field is required.

Chronic Meds RenewalNew Prescription

2

Who is the prescription for?* This field is required.(Names as they appear on ID or Passport)

First Name

Last Name

3

Email* This field is required.Double check so that your documents and prescriptions don't get lost in the mail!

example@example.com

4

Phone Number* This field is required.How can we reach you? We'll send you a WhatsApp after processing your request.

Please enter a valid phone number.

5

Which medications would you like to request?* This field is required.You can also state what it is you need the medications for. NOTE: Antibiotics will generally only be prescribed through a consultation with one of our doctors, but we'll let you know about this!

Eg. "Something for nausea or motion-sickness, I'm travelling overseas."

6

Which medications do you need?* This field is required.Write the names, strength and dosages - as well as frequency that you take each. Do your best if you're unsure.

Eg. "Pharmapress 10mg twice a day"

7

Have you taken this medication before?

YESNO

8

Any particular reason for requesting this prescription?* This field is required.Tell our Doctors a little bit about why you've made this request.

Eg: "I hurt my back lifting a heavy object and I need a Voltaren injection ASAP!"

9

Who should we send your prescription to?(We'll WhatsApp or Email it to you, or a particular pharmacy of your choice)

Send it to MeTo a Pharmacy

10

Please enter the pharmacy's script-receiving email address or pharmacy name below:Please ensure this is correct, or it could get lost in the mail!