For GHA issued prescriptions only
Name
First Name
Last Name
Address
Date of Birth
/
Day
/
Month
Year
Date Picker Icon
Medical Card Num.
Serial Number
Status
Dispense not before
/
Day
/
Month
Year
Date Picker Icon
Dispense not after
/
Day
/
Month
Year
Date Picker Icon
Comments
Enter the message as it's shown
*
Please note . If prescriptions are about to expire (ie. in less than 3 days) please phone us first to ensure that we are able to process them in time. We do not accept responsibility for prescriptions which are forwarded to us with a limited time processing window.
Submit
Should be Empty: