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To use this service, please fill in ALL the fields in the following Self-Collection form:

*Indicates mandatory field
Patient's NRIC/FIN*:
(As printed on the prescription)

Medicines that patient wishes to collect*: All the balance Selected medicines

Contact Person*:
(Please indicate who to call to confirm your order)

Contact Number*:
(Please provide a number that is easily contactable)
(Singapore numbers only)
Preferred mode of payment*:
Cash / NETS / Credit Cards
Medisave
Alexandra Health Card(AHC)
Others

Preferred date of collection*:
Date:

I have read and agree to the terms and conditions.