Medication Refill Form

Dear Patient,
The delivery service and treatment from will be temporarily stopped, and will be back to service after the Eid Al-Adha vacation on Sunday, June 23, 2024, and we wish you a happy Eid.

Patient MRN *

Note:

In case there is more than one prescription that needs to be mailed to the same address, please fill the form once and add all required medical record numbers.

Patient Name *

National ID *

Mobile Number *

Other Mobile Number

Pickup method: Through express mail (Registered only, conditions apply)

Address

House No.

Street Name

District *

City *

Zip Code

Notes

Service Terms and Conditions

The form should be filled out from 8 am to 3 pm.
Forms submitted after 3 pm will be received the following working day.
Prescription refill requests made during the weekend (Friday & Saturday) will be processed on Sunday morning.

Medication Refill Prescription *

I acknowledge that I have a medication refill prescription

Delivery Fees *

I acknowledge that there are delivery fees to be paid to the shipping company upon arrival

Leave this field blank

Published on: 24 March 2019

Last update on: 23 June 2024

Page views: 132045

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