Please complete the relevant form below, for us to correctly interpret your requirements:


“Over the Counter” Medication

    Your Name and Surname


    New CustomerExisting CustomerCash Order (COD)


    If you are an Existing Customer,
    please enter your HealthPharm Account Number:


    Cell Number


    Landline Number


    Your Email (required)


    Your Docter's Surname


    Subject

    Your Message



    Prescription Medication

      Your Name and Surname


      New CustomerExisting CustomerCash Order (COD)


      If you are an Existing Customer,
      please enter your HealthPharm Account Number:


      Cell Number


      Landline Number


      Your Email (required)


      Your Docter's Surname


      Prescription Number


      3 Months6 Months

      Please scan and upload your prescription (not bigger than 1mb per attachment):


      Additional Products / Items