Prescription Re-Order Form

First Name

Surname

Date of Birth

dd/mm/yyyy

Phone Number

Email Address

This email address may be used to contact you regarding your prescription request or any prescription queries.

Physical Address

Usual Pharmacy

Unichem Kerikeri Pharmacy. Unichem Kerimed Pharmacy. Unichem Kerikeri Medical Centre Pharmacy. Waipapa Unichem Pharmacy.

Prescription Details

What medications would you like your repeats for?

Fulfilment Options:

Delivered, or you will collect in store.

Please Note:

If someone is not going to be home to accept delivery, then please advise where we can leave your package that is hidden from view. WE can only leave packages by prior agreement. A signature may be required on receipt of medications.

Special Delivery Instructions

Please also notify us if there is a dog loose on the property so that we can call you from the car and arrange for you to restrain the dog or meet our driver at the gate.

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