Scribd
Upload
37 views1 page

BOTOX 1st Order May 2024

This order form is for Dr. Balaji Kalband to purchase 20 vials of BOTOX® (100 Units) from ICON Pharmacy, with an effective date of March 2024. The order was placed on May 13, 2024, and includes contact information for delivery and notifications. A prescription for the BOTOX® will be provided within 7 days of treatment, and personal data collected is subject to AbbVie's Privacy Notice.

Uploaded by

balaji
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
37 views1 page

BOTOX 1st Order May 2024

This order form is for Dr. Balaji Kalband to purchase 20 vials of BOTOX® (100 Units) from ICON Pharmacy, with an effective date of March 2024. The order was placed on May 13, 2024, and includes contact information for delivery and notifications. A prescription for the BOTOX® will be provided within 7 days of treatment, and personal data collected is subject to AbbVie's Privacy Notice.

Uploaded by

balaji
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

ORDER FORM

PBS Effective date March 2024

TO PLACE ORDER PLEASE EMAIL FORM TO CUSTOMER SERVICE


EMAIL: [email protected]
Doctor Name Dr Balaji Kalband
Account number 59764323

Delivery Address Agios Health Specialist Medical Centre

Shop 3/23 Hassall Street

Suburb/City Parramatta

State/Postcode 2150

Order date 13/05/2024 Contact phone 02 8608 2262

Contact name Shaba Tarafdar Mobile phone 04311 42262

Contact email [email protected]

✔ Check to receive Email and / or SMS Shipping Event Notifications for this order
(Please ensure Mobile number and email address are filled above to receive notifications)

ICON (formerly Epic) Pharmacy


Pharmacy Name
PO BOX 58, Deakin West, ACT, 2600

Product code Product Order Qty (Number of vials)


91223ED BOTOX® 1 Vial (100 Units) 20

Acknowledgement
IMPORTANT: I acknowledge that a prescription for BOTOX® (botulinum toxin type A)
used from this order will be provided within 7 days of treatment.
Doctor Signature Date

13/05/2024

Special Instructions:

AbbVie Pty Ltd, Mascot, NSW 2020. ABN 48 156 384 262.
© 2023 AbbVie. All rights reserved. BOTOX® and its design are trademarks of Allergan, Inc., an AbbVie company. PH 1800 252 224.
Date of preparation April 2023. AU-BTX-230045
Personal data provided on this form is collected by AbbVie Pty Ltd for the purpose of processing your order and is subject to our Privacy Notice [https://www.abbvie.com.au/privacy.html],
which describes how AbbVie collects and processes your personal data and your data privacy rights. Providing your personal data to us is voluntary, but if you decide not to provide us
with your personal data, AbbVie may not be able to process your order.

You might also like