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CUSTOMER ORDER FORM
Please request any items that you require. We will do our best to deliver everything you have asked for. Staff will contact you if they need any more information. Please order ONE MONTH SUPPLY to reduce the number of deliveries and to make sure our suppliers don't run out.
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Name
*
First
Last
Phone
*
Email
Please select type of items needed
Prescriptions
Non-prescription items
Prescription File Upload
Click or drag files to this area to upload.
You can upload up to 10 files.
Click in the box and use your camera to take pictures of your prescriptions
Please list any non-prescription items here
Feel free to write down any other details you wish to communicate to the pharmacy
Submit