Order form

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
Last Name________________________________________
Home Address____________________________________
Suburb___________________State_____Postcode_______ Delivery Address
Business Name____________________________________ Delivery Address___________________________________ Suburb_________________State_____Postcode_________ Work ( )_________________Fax ( )______________ Contact phone number ( )_________________________ Mobile___________________________________________ Email____________________________________________ Signature________________________________________ 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 :
Address (if different to above)____________________________________
Do you have any drug allergies?

Suburb_____________________________________Postcode_________
No drug allergies Aspirin Penicillin Sulfa Date of birth____/____/____ Sex M F
Health Care Card/Pension Card/ Safety Net Entitlement Card. You must
Other ______________________________________________ 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.___________ Address_____________________________________________________

______________________________________Postcode______________
_______________________________________________
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 $
SUBTOTAL
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
TOTAL ORDER
Would you like us to keep your repeat prescriptions? YES NO
(You can simply ring us to have your repeat prescription dispensed)

Source: http://www.homepharmacy.com.au/homepharmacy_order_form.pdf