Orderfom.pub

Compounding Service Order Form—LISMORE Placing your order 1. Phone or email us if you would like information on services, including prices
2. Complete the form below, placing a in the appropriate boxes 3. Mail your order form and original current prescription to us Customer details
Contact information: Mr Mrs Miss Ms Other title:_____ First Name:__________________________Last Name:_____________________________ Postal Address:_____________________________________________________________ ___________________________________Postcode:_______________________________ Phone number (daytime):_________________Mobile Number:__________________________ Prescription Repeats held New script attached
Item/s required: Quantity:
_________________________________________ _______________________
_________________________________________ _______________________
_________________________________________ _______________________
(eg progesterone cream/DHEA capsules etc) (eg 2 jars or 50 capsules etc)
Official claiming receipt for private health fund required? Yes No Payment method
Visa Mastercard American Express Cheque/Money order Direct Deposit
Card holder’s name:__________________________________________________________
Card number
Expiry date /
For ease of ordering can we retain your payment details? Yes No
Direct Deposit
If you would like to pay online or at a bank by direct deposit please find the bank details below:
Account name: Pharmacy Management Lismore
BSB: 062 674
Account Number: 1016 6831
All of our compounded services are sent via express post to enable fast delivery and tracking of the parcel. Traditional preparations
We also make traditional remedies using original formulas that are available without
prescription. Please turn the page for further details.
_________________________________________________________________________ Lab Address: 89-93 Keen Street Lismore NSW 2480 Email: lismorecompounding@blooms.net.au Postal Address: PO Box 133 Lismore NSW 2480 Website: www.blooms.net.au Free call number: 1800 243 647 Proprietor: Elaine Unsworth B.Pharm Fax number: 02 66 214 020 Proprietor: Greg Cadorin B.Pharm ABOUT US:
Supplying compounded medications all over Australia Based in Lismore, in northern New South Wales We use both traditional and modern pharmacy methods to prepare special medications to prescription requirements. OUR PRODUCTS:
Bio-identical hormones for men and women Analgesics (including pain relief creams) We have a large range of bio-identical hormone products in a variety of dosage forms available on prescription from your Doctor. WHY USE US?
Our prices are highly competitive with other compounding chemists We have been providing compounding as a service for over 10 years Provide free information packs to Doctors on their request Our special base cream is a propriety formula made from locally-produced Macadamia oil. TRADITIONAL PREPARATIONS—Available without prescription
Traditional NE Ointment 25g
Contains an antiseptic and may reduce the itch and discomfort ointments
associated with dermatitis and psoriasis. May help in the treatment of eczema, pimples, blemishes, An antiseptic ointment with natural oils for the skin that may Natural ingredient restores tone to over-relaxed throat muscles 75.00 remedies
and may be beneficial in the treatment snoring. One bottle lasts three months. An iodine supplement to be taken diluted in water. Purchasing Top-to-toe Macadamia Oil 200mL
A pure, cold-pressed oil produced in northern NSW. Excellent Skincare
Works as a barrier cream and may also nourish the skin. May help 8.95 Pure and mild facial toner for all skin types. Use after cleansing Wonderful for face and body. With macadamia oil, the “secret” ingredient of many big-name cosmetic brands. May soothe the itch and discomfort associated with mosquito outdoors
bites. It may assist in taking the heat out of sunburnt skin. Helps to soothe insect bites, especially sandflies. May assist in

Source: http://www.roperandparry.com.au/OrderFom.pdf