COMPOUND ORDERINGYour Name (required)* First Last Name on Prescription (if not for yourself) First Last Do you have any allergies or sensitivities? (required)* Yes NoPlease briefly listNoneStreet Address* Street Address Address Line 2 Suburb State Post Code Preferred main contact number (required)*Secondary contact numberDo you wish for us to contact you when your order is complete? (required):* Yes NoWhich contact method(s) would you prefer? Email Phone Call Text MessageEmail address (required)**Please note, @yahoo.com and @yahoo.com.au email address are incompatible with this system and will not be received by the pharmacy. Please use a different account or call the store to ensure your order is received. Enter Email Confirm Email Number of items to order (required)* 1 2 3****If you wish to order more than 3 items, please place additional orders.Item 1 (required)*Please be descriptive and include medication name, strength and quantity. Unclear descriptions may delay your order.Item 1 - Flavour (if applicable)See flavour listItem 1 - Is the script on file or attached below (required)* On File Attached Item 2Please be descriptive and include medication name, strength and quantity. Unclear descriptions may delay your order.Item 2 - Flavour (if applicable)See flavour listItem 2 - Is the script on file or attached below On File Attached Item 3Please be descriptive and include medication name, strength and quantity. Unclear descriptions may delay your order.Item 3 - Flavour (if applicable)See flavour listItem 3 - Is the script on file or attached below On File Attached Do you want us to file the repeats for easier ordering in the future? (required)* Yes NoHow would you like to receive your compound? (required)* In-Store Pickup Post (additional $13.00)Postal address Same as abovePostal Address* Street Address Address Line 2 Suburb State Post Code Special instructionsUpload photo/scan of script Drop files here or Select filesMax. file size: 25 MB, Max. files: 4.CAPTCHAName First Last
