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Please enter your full name and address including a valid phone number, as your order will otherwise be declined by our bank for security reason! Please enter your name and address without using any symbols like № o & ? ! etc.


Title: Mr.Ms.
First Name:
Last Name:
Date of Birth:
E-mail Address:




Billing/Shipping Address:

(If your billing address differs from your shipping address, please enter your billing address first, you can add your shipping address on the next page).

Please enter your address without using any symbols like o & ? ! etc.
Información especial para los clientes españoles!
Por favor, no utilice el símbolo o, como nuestro banco disminuirá su pedido.



Address 1:
Address 2:
City:
State/County:
Zip Code / Postcode:
Country:

It is mandatory to enter a state, in case you are from a country that does not have a state or province, please enter 00 in the field for the state (two digits are required).




 

Telephone Number:

Please provide a valid phone number, preferably a mobile number.

Orders placed without a valid phone number that matches to the country of your billing address, will be declined by our bank.

Sometimes a representative of our bank will call to verify the order. If your phone number is not correct, your order may be cancelled.




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Enter a Password:
Confirm Password:


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Mediplus Pharmaceuticals Ltd 111 North Bridge Road, #21-01, Singapore 179098

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