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Online Compound Medicine Order Form
First Name
*
Last Name
*
Phone
*
Email
*
Are you ordering a troche?
*
No
Yes
Please select your preferred flavour
*
Peppermint
Aniseed
Tutti Frutti
Chocolate
Banana
Orange
Grape
Raspberry
Strawberry
Coconut
Spearmint
Butterscotch
Do you have any allergies?
*
No
Yes
Please list any known allergies
Are you currently taking any medications or supplements?
*
No
Yes
Please list your medications below
*
Please list your supplements below
*
Do you have any current or past health conditions?
*
No
Yes
Please select any that apply or specify other
*
Arthritis
Asthma
Chemical sensitivities
Coeliac disease
Diabetes
Epilepsy
Glaucoma
Heart condition
High blood pressure
Inflammatory Bowel Disease
Lactose intolerance
Stomach ulcers
Thyroid
Other medical conditions
Please specify your medical conditions
*
Are you pregnant?
*
No
Yes
Are you breastfeeding?
*
No
Yes
Do you have your prescription available to upload?
*
Yes
No, the script is on file with Customcare Pharmacy
Please upload a copy of your prescription
*
Accepted file types: pdf, jpg, png.