HomePharmacy.com.au order form
“Lowest Prices & Home Delivery are
just the beginning …”
(Require for prescription and offline purchases) Phone 1800 333 878 Fax 61- 73841 6733
HomePharmacy.com.au,1367 Beenleigh Rd, Kuraby, Qld 4112
Mr/Mrs/Ms/Dr. First Name__________________________ Payment Detail
Work ( )_________________Fax ( )______________
Contact phone number ( )_________________________
Please complete the below information if you are sending prescriptions or require “Patient Profile require items”
Patient’s full Name_____________________________________________
Please tick [ ] the appropriate box(es) below :
if different to above)____________________________________
Do you have any drug allergies?
No drug allergies Aspirin Penicillin Sulfa
Date of birth____/____/____ Sex M F
Health Care Card/Pension Card/ Safety Net Entitlement Card. You must
include a photocopy of your card the first time you use us.
Do you have any of the following medical conditions?
Stomach ulcers High blood pressure Glaucoma
No chronic conditions Arthritis Diabetes
Medicare Care Number
Person number on medicare Card 1 2 3 4 5
Other condition _____________________________________________
Your Doctor’s Name__________________________________________
Are you on any other medication? Please include both
prescription and non-prescription medication.___________
Doctor’s Phone_____________________Fax No____________________
Please complete all details of your order in full including prescriptions
Please give full details of each product (Please attach addition form if insufficient) please note: If you ordering prescription for more than one person please fill out an order form for each individual person.
Product number NAME OF PRODUCT SIZE QUANTITY PRICE $
Would you like us to substitute a less expensive equivalent brand if available and if your doctor permits?
PLUS POSTAGE & HANDLING
FREE FOR ORDERS OVER $150.00 or
Order with NHS prices of $5.90 & $36.10
Do you require a receipt for your private health fund? YES NO
Would you like us to keep your repeat prescriptions? YES NO
(You can simply ring us to have your repeat prescription dispensed)
Réjan Vigot Work addressLauney Research Unit for Molecular NeurocyberneticsRIKEN – Brain Science InstituteHirosawa 2-1, Wako, Saitama 351-0198, JapanTel.: +81(0)48-462-1111 (ext. 7488) Fax: +81(0)48-467-5485E-mail : [email protected] position2009- Researcher, Launey Research Unit, RIKEN – BSI, JapanUniversity Degrees1996 Ph. D. in Neurosciences, University of Paris XI, Orsay,
Global epidemiology of sexually transmitted diseases Global epidemiology of sexually transmitted diseases Urology Department, Mãe de Deus Hospital, Porto Alegre, RS 90450180, Brazil Abstract Sexually transmitted diseases (STDs) are among the first ten causes of unpleasant diseases in young adult malesin developing countries and the second major cause of unpleasant diseases in young adult