ENHANCED MEDICAL DELIVERY

* Indicates required field

What is the full name of the recipient? *

First

Last

Phone Number *

Email *

PICKUP ADDRESS

CAN YOU PROVIDE THE COMPLETE PICKUP ADDRESS, INCLUDING ANY SPECIFIC *

Line 1

Line 2

City

State

Zip Code

Country

DELIVERY ADDRESS:

Can you provide the complete delivery address, including any specific *

Line 1

Line 2

City

State

Zip Code

Country

PACKAGE DETAILS

What are the dimensions and weight of the package? *

DELIVERY TIMEFRAME:

By what date and time does this package need to be delivered? *

SPECIAL HANDLING:

Are there any special handling or care instructions for the package (e.g., fragile, refrigeration required)? *

BACKUP CONTACT:

Is there an alternate contact person or number in case the primary *

RETURN INSTRUCTIONS :

What should be done if the package can't be delivered (e.g., return to *

PAYMENT IS NEXT FOR DELIVERY

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