Chemist Direct Mail/Fax Ordering Form
Chemist Direct
99 Spring Street, Bondi Junction, NSW 2022
Australia
Phone [Sydney]: +61 2 9669 6426
Phone [Australia wide]: 1300 655 541
Fax: (612) 9389 5108

 
CONTACT DETAILS
Name:
Street Address:


City/Suburb:
Postcode:
State:
Country:
Phone:
Email:
SHIP TO: (Complete if different to contact details)
Name:
Street Address:


City/Suburb:
Postcode:
State:
Country:

Qty Products Item # (if known) Price Total
         
Sub-Total:  AUD$  
+ Shipping (Please contact Pharmacy Online):  AUD$  
Total:  AUD$  

Cheque
Money Order
American Express

Credit Card Name:
Credit Card Number:
Credit Expiry (mm/yy): /
Signature:

 

Please complete the below information if you are ordering prescription items:

Medicare Information:
Medicare card name:
Medicare card no:
Medicare expiry (mm/yyyy):
Medicare sub number (one digit number before your name:

Healthcare concession no:
Healthcare expiry (dd/mm/yyyy):

Pension no:
Pension expiry (mm/yyyy):

Repatriation no:
Repatriation expiry (mm/yyyy):
Repatriation card type (please circle): Gold / Other

Safety Net no:

Change to generic brand? (please circle): Yes / No
Would you like us to retain your repeat prescriptions? (please circle): Yes / No

 

Agreement: (please tick if agree)
I accept the terms & conditions.

Signature     Name
Date (dd/mm/yyyy) / /