Perscription Collect Booking Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Task Type
Prescription Pickup
My Products
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( X )
Prescription collection
Pickup and delivery of prescription medication
$25.00 NZD
$
25.00
NZD
Quantity
Details for the collection?
*
(Describe the task clearly – e.g. pick up unichem pharmacy hornby, Name on prescription)
Pharmacist aware HURRY HUB will be collecting prescription?
*
Yes
No
Unsure
Pickup location Details
(if applicable)
Drop-Off Location Details
(if applicable)
Booking Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Booking Time
*
Morning (8am–12pm)
Afternoon 12pm-3pm
Evening (3pm -5pm
ASAP / URGENT (extra chargers may apply
Any special instructions?
(Gate codes, parking info, contact person, etc.)
CHAIN-OF-CUSTODY UPLOAD
*
Browse Files
Drag and drop files here
Choose a file
Attached your Chain Of Custody authorization form for transport of controlled drugs
Cancel
of
Terms Agreement: I agree to the service terms and understand extra charges may apply
*
Submit
Submit
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