Pharmacy Delivery

This form is for Pharmacy pickups and deliveries shipped to and from registered Pharmacies only. All shipments should be securely packaged, labeled and ready to ship when you submit this pickup order.

If your pharmacy is not registered, please call customer service at: 631-629-4780 for assistance.

Shipping Order:

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Your Name: *

Pharmacy Name: *

Account Number: *

E-mail address: *

Recipient Code:

Name of Recipient: *

Delivery Address: *

Delivery City, State, Zip: *

Recipient Telephone: *

Delivery Deadline: *

Cooler Required

Other (please specify in notes)

Notes:

Captcha (spam protection code) *

I herby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

Note: Fields marked with * are required

ProntoRx

ProntoPak Courier Systems, Inc.

This order form is for Pharmacy pickups and deliveries shipped to and from registered Pharmacies only. All shipments should be securely packaged, labeled and ready to ship when you submit this pickup order.

Not registered? No Problem!

Just call us at: 631-629-4777 to place an order.

You can also contact customer service at: 631-629-4780 to register your Pharmacy for even faster ordering in the future.

Pharmacy Pickup Information:

Pharmacy ProntoCode:

Your Name:

Pharmacy Name:

Pharmacy Shipping Address:

Pharmacy City, State, Zip:

Pharmacy Email Address:

Pharmacy Telephone:

Alternate Pickup Contact Telephone:

[ ] Cooler Required

[ ] Other (Please specify in notes)

Notes:

Delivery Information:

Recipient ProntoCode:

Recipient's Name:

Alternate Recipient Name(s):

Delivery Address (include building, floor and/or apt.):

City, State, Zip:

Email Address:

Telephone:

Alternate Delivery Contact Telephone:

[ ] Additional Delivery Instructions (Please specify in Notes)

Notes:

[ Submit Order Details ]

[ Activate Order ]

The 'Activate Order' button would launch them to the paypal payment module to complete the transaction for the order. They would then get bounced back to a page setup on the ProntoPak site informing them that their order is activated and giving them them information they can use to check on the progress of their shipment, special offers, coupons, etc...

Note: The ProntoCodes would be numbers we can distribute to shippers and recipients to build a database that would at some point be integrated into the order processing but in the meantime provide us with useful marketing resources for promotion of services.

On-Demand Long Island Courier Services - Same Day & Route

Serving the New York Metropolitan Area & Beyond

Pickup: 631.629.4777 | Customer Svc: 631.629.4780

About Us | Services | Contact Us

For service information,

quotes and Pickup service

call: 631.629.4777

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