Quote / Purchase Request

Thank you for choosing SuperPharmacyPlus.

Please fill out the below form, and our Mobility Admin Team will be able to reply via email with a quote for the requested items, or contact you for further items.

Should you request further information, please contact us via cs@superpharmacyplus.com.au, or alternatively speak to our staff on
(07) 3355 3052.
Quote Request Type

Individualorganization / businessOther
Organization (if applicable)

Angels in ApronsAnglicareBluecareBrisbane North PHN Team CareCentacareCo.As.ItCommunifyDepartment of Veteran's AffairsFootprints IncSuncare Community Services LtdStay Balanced PhysiotherapyWesley Mission QueenslandAged Care Physio AUOther
Required Document

QuoteInvoiceOther
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:
  
  PrivateHome Care PackageNational Disability Insurance Scheme (NDIS)Insurance (Workcover or similar)Short-term Restorative Care (STRC)DVAPrimary Health Network (PHN)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
  
  Self-ManagedAgency ManagedPlan Managed
- Invoicing E-mail Address
  example@example.com
- NDIS Number
- NDIS Client DOB
  
  DayMonthYear
- Claim Number
- Case Manager / Contact
  {if applicable)
- Delivery required?*
  
  Pickup From SuperPharmacyPlusDeliver to other address (please input details below)*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?*
  
  Authority to LeaveSignature Required**
- 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: