Physician Stock Order – Dickson Chemist

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Clinic Name

Email for confirmation

Which prescriber is signing the stock order

Delivery Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Select medicine required below:

How many of this medicine do you need?

Select medicine required below: (copy)

How many of this medicine do you need? (copy)

Select medicine required below: (copy)

How many of this medicine do you need? (copy)

If this you

Anything not in the standard drug list or if you need more than 3 items please typebelow

If you have a physical document (for example a signed order) to upload then please upload it here.

Click or drag a file to this area to upload.