NATIONAL SKIN CENTRE (S) PTE LTD

1 Mandalay Road, Singapore (308205)

Tel: 63508454
Fax: 62536138 Website: http://www.nsc.gov.sg

NSC Pharmacy Home Delivery Form (local addresses in Singapore only)

I would like to have my medication delivered to my home/ office:
Full name of patient: ____________________________

Email Add: ___________________

Identification number: ____________________________

Contact No: __________________

Delivery address: __________________________________________

_________________________________________ S (

Items to be collected (please tick):

Full / partial * (please delete) supply of your prescription.
Partial prescription items:
Items

Quantity

Payment mode (please tick):

Cash

Visa

MasterCard

Note: Delivery fees for courier service and purchase of retail items cannot be billed to CSC
For payment by credit card, please fill in your card details:
Credit Card Number:_____________________

Card Expiry Date:_____ (month) ______ (year)

Signature: ______________________

I hereby give consent to release my personal and contact information for the purpose of this delivery and
acknowledge that I have read and agree to the Terms and Conditions, as stated below.
_____________________________________________________________________________
For Official Use Only by NSC Pharmacy Dept
Name: ________________________ Signature: ______________
Total Cost: 1) Retail/ Medication : $___________
3) Courier Fee

Date: ____________

2) Admin Fee: $____________________

:$____________ 4) Total amount: $_____________

*Terms and Conditions:

1. There is no exchange or refund of medications once purchased.
2. For cash payment options, payment must be made upon delivery, otherwise it will be deemed an
unsuccessful attempt and the parcel returned to NSC.
3. Delivery charge is applicable for each successful attempt. Please ensure there is someone at your home /
office to receive and pay for your medications / purchase at the scheduled date and time.
4. Home delivery service is not extended to temperature sensitive medications that need refrigeration.