Name

First Name

Last Name

Email

Phone Number

Date of birth DD/MM/YYYY

Medication 1 & Quantity

Example : "MEDICATION NAME X2"

Medicaiton 2 & Quantity

Example : "MEDICATION NAME X2"

Medication 3 & Quantity

Example : "MEDICATION NAME X2"

Delivery Address

Please confirm your full delivery address

Note

Please add any details we need to know

I authorise Mode to process payment (if your card is already stored with us) for requested medications plus a flat express shipping rate of $15 . Your Medication order will be filled by our partner pharmacy Dukasa Compounding. Their pharmacists will contact you via the phone number you have provided if we need any further information and to ensure the medication is correct for you.

This ensures the fastest dispatch of medication.

Yes

No, Please send me an invoice

Please call to update card details

Please note a surcharge may apply to card transactions.

I understand

Alternatively, your e-script can be taken to any pharmacy in Australia. Mode advises that we cannot guarantee all pharmacies will have medication in stock and medication might need to be ordered in (usually 7-14 days). Additional paperwork may be required at some pharmacies, please contact us to help you with this process.

Changes to medication are not permitted without doctor's approval. Please allow 48 hours for review. Additional fees may be payable if public pharmacies require a change in medication due to their stock shortages when medication is available via Mode Dispensary partners.