Orderform.rtf

ORDER FORM
FAX to (03) 9311 0024 or
SEND to Shop 12, 254 Hampshire Rd
Sunshine Vic 3020
PLEASE PRINT IN CAPITAL LETTERS
Mr/Mrs/Ms/Dr. First Name: ____________________________________Last Name: __________________________________________________________Home Address: ________________________________________________Suburb: ____________________________________ Post Code: _______________ IF DELIVERY ADDRESS IS DIFFERENT FROM THE ABOVE ADDRESS THEN PLEASE FILL IN BELOW
Business Name: _________________________________________________________________________________________________________________________________Delivery Address: _____________________________________________ Suburb: _____________________________________ Post Code: _______________ CONTACT PHONE NUMBER (WE MUST HAVE A PHONE NUMBER TO PROCESS YOUR ORDER
Home ( ) _____________________________________________ Mobile ( ) _________________________________________________Work ( ) _____________________________________________ Fax ( ) ________________________________________________Email ______________________________________________________________________________________________________________ PAYMENT METHODS
□Cheque/Money order for $_____________ □Credit Card □BANK CARD □VISA □MASTERCARD □DINERS □AMEX □□□□ □□□□ □□□□ □□□□ Expiry Date _____/_____ Contact phone Number ( ) _________________________ Signature __________________________________________________________________________________ ONLY SIGNED ORDERS CAN BE ACCEPTED. ORDER WILL ONLY BE SENT ONCE FUNDS HAVE
CLEARED.
_____________________________________________________________________________________________________
PATIENT PROFILE FOR PRESCRIPTION MEDICATION
Patients full Name: ____________________________Address (if different from above): ________________ Do you have any allergies to?
Suburb: _________________ Postcode: ___________ □ Aspirin □ Codeine □ Erythromycin □ Penicillin Date of birth : ___/___/___ Sex M □ F □Health Care Card/Pension card/Safety Net Entitlement Card □ Sulfa □ Tetracycline □ No allergies You must include a photocopy of your card the first time you use us.
□ Other please specify ________________________________ Do you have any medical conditions?□ Arthritis □ Asthma □ Diabetes □ Epilepsy □ Thyroid Medicare card number. Fill in all 11 boxes and the expiry date. The last digit is the number next to your Christian name.
□ Stomach Ulcers □ High Blood pressure □ Glaucoma □ Other please specify ________________________________ PLEASE COMPLETE ALL DETAILS OF YOUR ORDER
Original prescriptions must be posted with order prior to dispatch.
Name of Product
Please give full details of each product ordered
SUBTOTAL
Would you like us to substitute a less expensive is available and your doctor permits?
□ YES □ NO
Plus Postage & Handling
Free for orders over
Would you like a receipt for your private health fund? □ YES □ NO
Us to keep your repeat prescriptions on file? □ YES □ NO
TOTAL ORDER
PHARMACY SUPPLY ONLINE FAX: (03) 9311 0024 email [email protected]

Source: http://wponline.com.au/images/orderform.pdf