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 20193
