MEDPHARMA ORDER FORM To order, please fill out the form and select the quantities of the products you require. Name * First Name Last Name Pharmacy Name * Pharmacy Branch * Email Address * Contact Number * Betamed Cream 0 3 6 12 25 50 100 200 300 Betamed Ointment 0 3 6 12 25 50 100 200 300 Betamed-N Cream 0 3 6 12 25 50 100 200 300 Betamed-N Ointment 0 3 6 12 25 50 100 200 300 Candizole 25g (Out of Stock) 0 3 6 12 25 50 100 200 300 Candizole 30g (Out of Stock) 0 3 6 12 25 50 100 200 300 Candizole 45g (Out of Stock) 0 3 6 12 25 50 100 200 300 Cefproz 100ml 0 3 6 12 25 50 100 200 300 Ceframed 0 3 6 12 25 50 100 200 300 Claradone Mouth/Gargle 0 3 6 12 25 50 100 200 300 Claradone V Douch 0 3 6 12 25 50 100 200 300 Claradone Ointment (Out of Stock) 0 3 6 12 25 50 100 200 300 Clarazole Shampoo (Out of Stock) 0 3 6 12 25 50 100 200 300 Clarazole Cream 0 3 6 12 25 50 100 200 300 Diclon (Out of Stock) 0 3 6 12 25 50 100 200 300 Diphelin (Adults) 0 3 6 12 25 50 100 200 300 Diphelin Paediatric (Out of Stock) 0 3 6 12 25 50 100 200 300 Hairgaine For Men (Out of Stock) 0 3 6 12 25 50 100 200 300 Hairgaine For Women (Out of Stock) 0 3 6 12 25 50 100 200 300 Hairgaine Gel (Out of Stock) 0 3 6 12 25 50 100 200 300 Irokid 0 3 6 12 25 50 100 200 300 Medacin T Solution (Out of Stock) 0 3 6 12 25 50 100 200 300 Medacin T Gel (Out of Stock) 0 3 6 12 25 50 100 200 300 Medafen Susp. 0 3 6 12 25 50 100 200 300 Medvirox Cream (Out of Stock) 0 3 6 12 25 50 100 200 300 Pectomed Syp (Out of Stock) 0 3 6 12 25 50 100 200 300 Thank you!
