COMPOUND ORDERING - Carina Day and Night Pharmacy

Your Name (required)*

First Last

Do you have any allergies or sensitivities? (required)*

Yes
No

Please briefly list

Street Address*

Street Address Address Line 2 Suburb State Post Code

Preferred main contact number (required)*

Secondary contact number

Email 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

Do you wish for us to contact you when your order is complete? (required)*

No
Yes

Which contact method(s) would you prefer?

Email
Phone Call
Text Message

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 list

Item 1 - Is your script on file, attached below or being faxed from your Doctor? (required)*

On File
Attached
Being Faxed

Item 2*

Please be descriptive and include medication name, strength and quantity. Unclear descriptions may delay your order.

Item 2 - Flavour (if applicable)

See flavour list

Item 2 - Is your script on file, attached below or being faxed from your Doctor? (required)

On File
Attached
Being Faxed

Item 3*

Please be descriptive and include medication name, strength and quantity. Unclear descriptions may delay your order.

Item 3 - Flavour (if applicable)

See flavour list

Item 3 - Is your script on file, attached below or being faxed from your Doctor? (required)

On File
Attached
Being Faxed

Do you want us to file your repeats for easier ordering in the future? (required)*

No
Yes

How would you like to receive your compound? (required)*

In-Store Pickup
Post

Postal address

Same as above

Postal Address*

Street Address Address Line 2 Suburb State Post Code

Special instructions

Upload a copy of your script. Please make sure that your image is legible and of a reasonable size. Unreadable scripts may result in a delay in your order. Please note that you legally must provide the original copy of the script to the pharmacy.*

Drop files here or

Max. file size: 8 MB, Max. files: 6.

Maximum file size 5MB

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