Form - Renew Rx

Pharmacy/Organization Name *

Email *

Phone Number

Is the pharmacy within the facility registered by the PPB (Pharmacy & Poisons Board)? (We will confirm the details with PPB) *

Which delivery option do you prefer? (We suggest you cover the delivery fee at least within your county) *

What building is the facility from which the medicines are to be picked from located at? *

What street/road is the facility from which the medicines are to be picked from located at? *

Which county are the products being collected from? *

Add multiple products from the same facility

Product Name *

Generic Name

Brand Name

Strength

Dosage Form

Quantity *

Expiry Date *

Batch Number

Description

Renew Rx