Online Medicine Order Form

Use the Online Medicine Order Form to collect customers' personal details as well as their medical histories like allergies, medical conditions, current medications, and more. Click on the ‘Use this template’ and get started by collecting the details.

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How does this Online Medicine Order Form help?

Are you having an illness and want to order your medicine online? Use this template to ease the process for your customers and make it seamless for them to order medicines.

Pharmacies and medical stores can use this Online Medicine Order Form to collect their customer's information and serve them better. The form comes with ten simple questions asking customers about different things. They can choose from the options and send out the form for their medicine order.

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How to Use this Online Medicine Order Form

Use Zonka Feedback to create healthcare surveys to engage with your customers. Once you have created your survey, the distribution is quite easy, as you can reach your customers via Tablets, SMS, Email, Widgets and more.

You can customize the survey and make it stylish as you want. Choose the background image and add questions, choosing from different question types such as multiple choice, rating, opinion scales, and more.

10 Questions

11Screens

2 mins to complete

List of Online Medicine Order Form Questions

The following questions are included in this Online Medicine Order Form.

Could we know your name?
Can we have your E-mail ID?
Can we know your age?
Your Gender
Your Phone Number
Do you have any allergies?
What are the medications you are currently under?
Any existing medical conditions?
Please let us know the medicine you want to order.
How many quantities do you want?

Sign Up or Sign In on Zonka Feedback for free and try this Online Medicine Order Form to simplify online medicine ordering for patients and ease the understanding of customers and their symptoms for pharmacies.

FAQs about Online Medicine Order Form

1. How do you create an online medicine order form?

It’s easy to create a template with Zonka Feedback, you can choose the survey from our and dashboard and start using it straight away. You can also customize the questions in the survey template with a dropdown, textbox, and add logic as well. Then, you can publish the form and share it with the customers, so they can fill their orders online in a secure place.

2. What is an online medicine order form?

An online medicine order form is used by pharmacies or medical suppliers for collecting information about the customers such as their name, email id, age, any medical conditions they have.

3. Where can I use this Online Medicine Order Form?

You can use a QR code at your touchpoint. Another method is to send an email or SMS survey to the customer once the service is completed. If you don't have access to the internet, you can conduct offline surveys using kiosks, mobile devices, or tablets.

Create and send this Online Medicine Order Form