Patient Care

Please enter your particulars and click "Submit" at the end of the page

All fields marked with * are required

Name:*

NRIC No.:*

Date of Birth:*
(dd/mm/yyyy)

Third Party Payor:*

YesNo* If Yes, please fax or send in the document of proof.

Language Spoken:*

Delivery Address:*

Phone Number (H):*

Phone Number (O):

Handphone Number:

Email:*

Next Appointment Date:
(dd/mm/yyyy)

Proposed Delivery Date:
(dd/mm/yyyy)

Duration of Supply:

Month(s) Week(s)

Remarks

(max 360 characters)

Please allow at least 3 working days to process your request. The pharmacy staff will call to advise you of the delivery date
The medicine will be delivered on the agreed date between 12 noon to 6 pm
Please note that by clicking the Submit button below, you are agreeing to be bounded to the NHCS Pharmacy Courier Service Terms and Conditions, as well as agreeing to allow the NHCS Pharmacy staff to access to your medical records as contained within the NHCS databases (if such records exist) for the sole purpose of facilitating any medication refill within NHCS.