Your Pharmacy

Use this form to order prescription or over-the-counter medication on behalf of a patient in Zimbabwe. Once we receive your request, our team will coordinate with Your Pharmacy to prepare for collection or arrange delivery directly to the patient’s location.

Section 1: Sponsor Information

Your full name

Your Email Address For booking confirmation

Your Phone Number* Include international code

Section 2: Patient Information

Patient Full Name Person receiving care or services

Patient Phone Number For follow-up or doctor call

Section 3: Medication Details

Medication Name(s)*

Dosage and Instructions*

Prescription Upload (if required)

Click here to take picture or select file

Preferred Collection Schedule Select your referred delivery schedule

24 Hours (Emergency Collection) 48 Hours (Standard Collection) 72+ Hours (Flexible Collection)

Section 4: Additional Details

Patients Address (if delivery option is preferred)

Additional Notes / Special Requests or Instructions