NZ Fibromyalgia Information for New Zealand 01 October 2007

Order Form for N.Z. Guaifenesin New Zealand Orders
Please fax to Jacqui at (09) 264 1214 Any queries - ph Jacqui at (09) 264 1213
Or post to Jacqui at P.O.Box 76-455, Manukau, Auckland 2241, N.Z.
If using post, you may fax or email jacqui@voxau.com that your order is on it's way. make a large cross
against your choice
A. I require 100 capsules x 300mg Guai @ $NZ 60.00 plus courier @ $6.50 Total $ 66.50 A. _ _ _ _
($NZ 60.00 per 100)
B. I require 300 capsules x 300mg Guai @ $NZ 180.00 plus courier @ $6.50 Total $ 186.50 B. _ _ _ _
($NZ 60.00 per 100)
C. I require 500 capsules x 300mg Guai @ $NZ 300.00 plus courier @ $6.50 Total $ 306.50 C. _ _ _ _
($NZ 60.00 per 100)
D. I require 100 capsules x 600mg Guai @ $NZ 70.00 plus courier @ $6.50 Total $ 76.50 D. _ _ _ _
($NZ 70.00 per 100)
E. I require 300 capsules x 600mg Guai @ $NZ 210.00 plus courier @ $6.50 Total $ 216.50 E. _ _ _ _
($NZ 70.00 per 100)
F. I require 500 capsules x 600mg Guai @ $NZ 350.00 plus courier @ $6.50 Total $ 356.50 F. _ _ _ _
($NZ 70.00 per 100)
Payment details The Pharmacy prefers a CreditCard number please.

My Cheque I enclose my cheque for Amount $NZ _ _ _ _ - _ _
Please make cheques payable to Jacqui Leeden at Positive Living
OR
My credit card VISA / MasterCard (please circle one) Amount $NZ _ _ _ _ - _ _

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 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(for Courier delivery )
Suburb & City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

My email address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

My phone number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Please note: NZPost 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 download the Guaifenesin Fact Sheet & Prescription Form and give to your doctor to complete.
I may fax this order to (09) 264 1214 and will snail mail to P.O.Box 76-455, Manukau, Auckland 2241
WITH my prescription YES / NO First-time orders must answer YES.
OR This is a repeat order as stated on my valid scrip dated after 01 April 2007 YES / NO
N.B. A scrip is valid for six months from the date of your doctor's signature.
Please see the following notes on page 2 for the various ways you may send your scrip.
N. Z. Order form for N.Z. Guai - Valid from 01 October 2007. Guai order forms before this date are now invalid.

FURTHER NOTES (p2.)

A prescription is necessary for Medsafe purposes. If your doctor has followed the template, we are able to issue orders up to a maximum of 1,000caps x 300mgs or 500caps x 600mgs with the original scrip, if your doctor has specified this

There are three ways you may handle your order:

In all cases, we suggest you save this file to your hard drive.
Take a copy to fill out for this order.

1. If you are happy with online security, you may then close the file and attach to an email
with a scanned copy of your scrip. This is the easiest and fastest way to handle an order.
Send to jacqui@voxau.com (omit signature in emails)

2. Or you may then print out your order including your credit card details
and fax it through to Jacqui at 0064 9 264 1214 with a copy of your scrip.

3. Or you may then print out your order including your credit card details
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 its way.

In all cases, we ask that the scrip be sent asap by snail mail please, to
Jacqui at Positive Living, P.O. Box 76-455, Manukau, Auckland 2241, New Zealand.
We are able to issue orders up to a max. of 1,000 x 300mgs or 500 x 600mgs if we have the original scrip.
We must have the original to protect our pharmacist. Thank you.

Please Print in Black Pen Thank You for Your Order
"Positive Living" Guai Group New Zealand
Jacqui Leeden
Editor, "Positive Living" Publications & Website
Convenor, Auckland Fibromyalgia Support
Northern Region 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
N. Z. Order form for N.Z. Guai _ Valid from 01 October 2007 _ Guai order forms before this date are now invalid.