First Name (required)

Last Name (required)

Birthday.Please use this format: DD/MM/YYYY (required)

Phone number. A DAYTIME number we can call you on. (required)

Cell Phone. Please add your cellphone number if you have one.

Email (required). Please enter your email address.

Prescription Details

Your request. Please LIST Medicine name (s) + dose required

Medication Requested

We will ONLY contact you if an appointment with your doctor is needed, or if we require any further information to issue the prescription, otherwise you script will be available after 48 hours.