Name *

First Name

Last Name

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