Request Consultation Form
Eyangakithi Medicals
Customer Information
Name
First Name
Last Name
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the shipping information the same with customer information?
Yes
No
Shipping Information
Name
First Name
Last Name
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Order Details
Order Date
-
Month
-
Day
Year
Date
Order Type
Please Select
Consultation
Order Type
Please Select
Medication
Select your orders
prev
next
( X )
Consultation
Consultation
250.00
ZAR
Quantity
Medication
400.00
ZAR
Quantity
Other
1.00
ZAR
Quantity
Method of Payment
Please Select
Debit Card
Credit Card
Bank Transfer/Eft
PayPal
Supply Proof of Payment
Email
Whatsapp
Over the counter
NOTES:
We'll contact you within 24-48 hours after submitting this form.
Depending on availability, we might negotiate the shipping method.
If you have any questions, you can contact us at (076) 620-4598 or email us at
eyangakithicomm@gmail.com
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