Prescription Order Form

Fill in your prescription details and we'll deliver your medication to your doorstep within 24 hours.

Full Name

Email Address

Phone Number

Delivery Address

Medicine Name

Dosage Select dosage 250mg 500mg 750mg 1000mg Other (Specify in notes)

Quantity

Frequency Select frequency Once daily Twice daily Three times daily Four times daily As needed Other

Prescription Details

Please include doctor's name, clinic/hospital, diagnosis, and any relevant medical information.

Preferred Delivery Time Any time Morning (9 AM - 12 PM) Afternoon (12 PM - 4 PM) Evening (4 PM - 8 PM)

Additional Notes (Optional)

I confirm that I have a valid prescription for the medication I'm ordering

I agree to the privacy policy and terms of service

Submit Prescription Order