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ORDER FORM: fax: 07 55 266 207 telephone: 07 55 266 607
PLEASE POST ORIGINAL
PRESCRIPTION TO ENSURE PROMPT DELIVERY OF MEDICATION.
NAME:
POSTAL ADDRESS:
TELEPHONE: (home/work/mobile)
FAX:
EMAIL ADDRESS:
ANY KNOWN ALLERGIES?
DOCTOR:
TYPE OF MEDICATION PRESCRIBED:
TROCHES flavours
: Lemon, butterscotch, vanilla, choc peppermint, peppermint, spearmint,
chocolate, marshmallow )
Sweetener:
stevia
*stevia is a natural plant-based sweetener.
CREAM (50g, 100g, 60g)
CAPSULES (x30, x50, x60,
x100)
*for other types of medications or flavours please contact us directly
PREFERENCES/COMMENTS:
SPECIFIC POSTAL DELIVERY INSTRUCTIONS (if any):
PAYMENT DETAILS: The mortar & pestle will contact
you to finalise payment details, please do not enter your card number or
details on this form.
Thank you very much, we look forward to speaking with you soon!