TJ Pharma Compounding Pharmacy

Prescription Orders

Patient

Name  _____________________________________________________________________________

Phone _____________________________________________________________________________

Pick-Up

1. Fax or e-mail the prescription and this form to start the preparation of your compounded medication

2. Present your prescription at TJ Pharma to pick up your medication

Delivery

1. Complete delivery consent details below

2. Fax or e-mail the prescription and this form to start the preparation of your compounded medication

3. Mail the prescription and this form to TJ Pharma Compounding

I, __________________________________________ (patient) hereby authorise TJ Pharma Compounding to deliver my prescription to:

Name_____________________________________________________________________

Address _____________________________________________________Postcode_____________

Signed_______________________________________________Date_________________

Please Note:

A. Nationwide Delivery $10 (special items may incur a surcharge like refrigeration)

B. Deliveries are forwarded within 24 hours of receiving a valid prescription

C.  Estimated delivery time is 1-2 working days

Contact details

Phone 02 8964 9492          Fax 02 8021 6068

Email  Info@tjpharma.com.au

Please print this order form and email or fax to TJ Pharma.