Order Form for N.Z. Guaifenesin Orders for Country Outside N.Z.
My card number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiry Date _ _ / _ _
Name on card _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Please note: You will receive a full receipt from the chemist for Disability, WINZ or other purposes
Address Details
My full name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
My street address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Suburb, City, Country _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
My email address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
My phone number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Please note: FedEx Courier parcels will need to be signed on delivery
Doctor's Details
My Doctor DR _ _ _ _ _ _ _ _ _ _ _ _ _ _ (first name) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (surname)
Clinic (if applicable) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Med No. _ _ _ _ _ _ _
Doctor's Full Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Please note: We cannot accept any liability for orders held up by Customs or lost in the country of delivery
Please download the Guaifenesin Fact Sheet
and Prescription Form & give to your doctor to complete.
I may fax my order to 649 264 1214 then will mail to P.O.Box 76-244, Manukau, Auckland 2241, N. Z.
WITH my prescription
YES / NO First time Orders must answer YES.
OR This is a repeat order as stated on my initial scrip dated after 01 August 2006
YES / NO
Receipt of a Prescription is necessary for both the Pharmacy and Customs purposes.
Overseas Order form for N.Z. Guai _ Valid from 5 August 2006 _ Order forms & scrip before this date are now invalid.
FURTHER NOTES (p2.)
Your doctor's prescription is necessary for both our Pharmacy and Customs purposes
and we are able to issue repeat orders to a maximum of 1,000caps x 300mg or 500caps x 600mg with the original scrip if it has followed our template.
Please note: Although we will do our utmost to help you, we cannot accept any liability for orders held up by Customs or lost in the country of delivery.
There are three ways you may handle your order:
Take a copy to fill out for this order.
Accompanied by a scanned scrip, this is the easiest and fastest way to handle an order.
Send to jacqui@voxau.com (omit signature in emails)
and fax it through to Jacqui at 0064 9 264 1214 with a copy of your scrip.
and send it and scrip by snail mail to:
Jacqui at Positive Living, P.O. Box 76-455, Manukau, Auckland 2241, New Zealand.
In this case it is wise to inform jacqui@voxau.com that an order is on it's way.
Jacqui at Positive Living, P.O. Box 76-455, Manukau, Auckland 2241, New Zealand.
We are able to issue repeat orders to the maximums above, if we have the original scrip.
We must have the original to protect our pharmacist here
and to have a doctor's authority if there are any problems with your Customs. Thank you.
Please Print in Black Pen
Thank You for Your Order
"Positive Living" Guai Group New Zealand
Jacqui Leeden
Overseas Order form for N.Z. Guai _ Valid from 5 August 2006 _ Order forms & scrip before this date are now invalid.
Editor, "Positive Living" Publications & Website
Convenor, Auckland Fibromyalgia Support
Northern Regional Advisory Group, Arthritis New Zealand
National Representative, Governing Body, Arthritis New Zealand
P.O. Box 76-455, Manukau, Auckland 2241
WWW.VOXAU.COM FOR FIBROMYALGIA AND OOS/RSI NEWS
Ph +649 264 1213 jacqui@voxau.com Fx +649 264 1214