Prescription & Medication Request

Patient information

First name*

Last name*

Date of birth*

Passport / ID number*

Phone number*

Email address*

Preferred contact method*

Preferred pharmacy (optional)

Doctor who issued the prescription (optional)

Upload prescription and ID document

Choose filesPDF, JPG, JPEG or PNG — maximum 10 MB per file

Delivery

Home delivery by MiReceptNo queues — we bring your order home. The total with delivery is sent to you.

Delivery address*

Delivery notes

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Personal note

Consent

I confirm that the information provided is accurate and that I authorize CareOnTrip / the selected pharmacy to process this medication request. See our Privacy Policy and Terms & Conditions.