Patient Order Form – BMM Compounding

*First Name*

*Last Name*

*Email*

*Mobile Phone Number*

Upload up to five Scripts (image of complete paper prescription or eRx token) Upload a file or drag and drop. jpg, jpeg, jpe, png, pdf, heic up to 10MB

e-script token code(s)

*Are you an existing client?*

*Repeats (Paper Prescriptions) – I would like to*

*Pickup or Delivery?*

Pickup my medication at a partnered store of my choice (we can provide you options based on your location)

Send me an invoice and post my order directly to me (Free EXPRESS post if over $50 OR if under $50 then free STANDARD post or $10 for EXPRESS, $25 for temperature sensitive). Please note preference in your message below - we will advise if refrigeration is required.

Select a store to collect from:*

Message

*I acknowledge and agree that: *

For legal compliance, paper prescriptions for PICKUP orders require me to bring in my ORIGINAL hardcopy prescription upon collection. Should I fail to do so, my medication will not be released to me.

For legal compliance, paper prescriptions for POSTAGE orders require me to post my ORIGINAL hardcopy prescription in the Reply Paid envelope enclosed with my order. Should I fail to do so, no further orders I place (for repeats or new prescriptions) will be processed.

For POSTAGE orders: All temperature sensitive orders are ONLY posted on Monday to Wednesday in order to ensure strict quality control.

Customer/Patient Order Form