Your name (first and surname) *

Dermatologist *

• Dr Todd Gunson
• Dr Paul Le Grice
• Dr Fergus Oliver
• Dr Denesh Patel
• Dr Chin-Yun Lin
• Dr Bob Chan

Email address *

I accept that a fee of $35 to 40 will usually apply *

• Yes
• No

Delivery method *

• Send directly to a pharmacy
• Pick up from Remuera Road

Pharmacy name and street address

Prescription items requested and quantities of each *

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