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Order your Prescription online (please allow 48 hours for this to be processed)
* indicates required information
Name: *
Contact Number: *
Email address: *
Name of drug: *		eg: Paracetamol
Strength: *		eg: 5oomgs
Number taken : *		eg: 2
Frequency: *	Daily Morning Night Twice daily Three times daily Four times daily As required Other (please state below)	Please choose
Name of drug:
Strength:
Number taken :
Frequency:	Daily Morning Night Twice daily Three times daily Four times daily As required Other (please state below)
Name of drug:
Strength:
Number taken :
Frequency:	Daily Morning Night Twice daily Three times daily Four times daily As required Other (please state below)
Name of drug:
Strength:
Number taken :
Frequency:	Daily Morning Night Twice daily Three times daily Four times daily As required Other (please state below)