Medicine Order Form

+27 72 682 0900

info@abovax.com

If you are ready to submit your direct medicine request, please complete the information below. Please complete all required sections. Once submitted, we aim to finalise all confirmed medicine requests to ensure fulfilment of orders within 24 – 48-hours.

PART 1:

1. Please indicate and confirm

Doctor Pharmacy Patient

2. Confirmation of jurisdictional Data

Nationality Residancy

3. Patient information

Title First name (required) Last name (required)

Email (required) Phone Number (required)

Gender (required)

Date of Birth (required) Is a diagnosis confirmed?

Patient script Attachments

4. Medication or treatment therapy required

Medication (required) Dosage (required) Duration (required)

Is it of chronic or repeat? Yes no

To be completed if you have answered 'Yes' to the above

5. Payment information

Payer (required) Payment method (required)

6. Delivery/Collection information

Country (required) Collection Point

Address (required)

Recipient Name (required)

Contact Number (required)

PART 2: Health Provider Information

7. Please indicate and confirm

Individual provider/Pharmacist

Practice/Company

Reference Number (required) if you have answered 'No' complete section 9 below

8. Please provide the full names, registration details and credentials of health provider or practice/company:

Registration date (required)

Attachments

9. Confirmation

I do confirm that I have accurately completed and provided all the information required to facilitate my direct medicine order. I hereby authorize ABX Health and their authorized partners to contact me in relation to my medicine order by way of email, phone, or any other communication channel deemed to be suited.