Quote / Purchase Request

We have now moved to a NEW (Automated) sytem for creating quotes.
Please go to https://superpharmacyplus.com.au/request-quote/ where you will be able to select the relevant products, select shipping and receive a quote immediately!
Quote Request Type

Other
Organization (if applicable)

Other
Required Document

Other
Your Name

First NameLast Name
Client's Name
John Smith
Your E-mail
example@example.com
Your Phone Number
- Client Name
  
  First NameLast Name
- Client Phone Number
  If applicable
- Relevant clinical notes:
- Upload a file
  
  If applicable (script / notes etc)
  Cancelof
- Funding Type:
  
  Other
- Site ID
- BlueCare ID
- As your order is regarding a Veteran, please note that the DVA MFS Rehabilitation Appliances Program can be accessed via our separate form:
  
  SuperPharmacyPlus DVA RAP Request Form (Electronic)
- HCP Provider Organisation
- Billing Address
  (if applicable)
- NDIS Funding Type
- Invoicing E-mail Address
  example@example.com
- NDIS Number
- NDIS Client DOB
  
  DayMonthYear
  2 digit day, 2 digit month, 4 digit year
- Claim Number
- Case Manager / Contact
  {if applicable)
- Delivery required?
  
  Other
- Delivery Address
  
  Street Address
  
  Street Address Line 2
  
  SuburbState
  
  Postcode
- Client Email for Tracking Information
- Can our courier leave the package if the client is not home?
- Special Delivery Instructions
- ** Australia Post no longer leaves physical cards when they thre is an unsuccessful delivery attempt. By selecting "Signature Required" you acknowledge you have included the client's phone number so that they can be contacted by Australia Post
- Products Required
  Please include quantity, product code (if known) and colour?
- Other Comments
- Should be Empty: