Prescription Form

IMPORTANT: Compounded prescription orders must be patient-specific. In accordance with Poison Act 1952, kindly fill in the prescription form completely. Thank you.

To : AALSUM PHARMAS SDN BHD
36-3, Setia Avenue,
Jalan Setia Prima S U 13/S,
Setia Alam, 40170 Shah Alam,
Selangor.
T : 03 – 3359 3630
E : aalsumpharmas@gmail.com
Doctor's Name : MMC No :

Please compound the following medication(s):

Date : Patient's Name :
Patient's IC No : Patient's Address :
No. Medication Directions for use Quantity

Remarks :

Free Courier / Delivery when order total

>RM 300 West Malaysia

>RM 600 East Malaysia

Please note this list is non-exhaustive and only includes the prescribed dosage and combinations.
For items not listed, please contact Aalsum Pharmas for more information (aalsumpharmas@gmail.com).