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Delivery / Collection of Medication request form.

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​Requirements
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  • ​Full Name & Surname
  • Residential Address
  • Delivery Address* excludes collection
  • Contact Details
  • ​​Medical Aid Details* excludes private patients

 

*We respect your privacy and take protecting it seriously. Pierau Pharmacy covers the collection, use and disclosure of information we collect through our website. The use of information collected through our website shall be limited to the purpose of providing the service for which the Client has engaged Pierau Pharmacy Website.

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