Order Form

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*Please ensure that you fill in all of the required details.

Personal Details

Product Details

Appointment location the patient go to.
Appointment location the patient go to.
Appointment location the patient go to.
Appointment location the patient go to.

[[ms]]Alamat:[[en]]Address:

No. 69B, Jeti 4, Kampong Bolkiah B, BK1325, Negara Brunei Darussalam​

Please enter your Tracking Number provided by the E-commerce Platform.
Nature of the product. For example: Cotton T-Shirt
For example: Shopee Malaysia
Nature of the product. For example: Cotton T-Shirt
Please select the currency of total value of your parcel.

Item Details

Enter numbers only.
No currency required to enter (E.g. RM, BND)

Please enter the item price of your parcel.

Estimated Delivery Date

Receiver Information

Charges Details

Notes:
  • Paying patient will be charged 3% or $2 surcharge (whichever is higher).
  • Maximum of $100 for payment on behalf.
Notes:
  • Paying patient will be charged 3% or $2 surcharge (whichever is higher).
  • Maximum of $300 for payment on behalf.
  • Patient can also choose to pay directly to JPMC.

Order Summary

Personal Details

Name:
House / Unit No:
E-mail:
Phone Number:
Additional Phone Number:

Product Details

Product Type:
Patient's Number:
Patient's Date of Birth:
IC-Number / Passport:
Health Centre:
Parcel Tracking Number:
Go Rush Receiving Country:
Shipment Method:
E-Commerce Name:
Commodities:
Currency:
Weight (KG):
Permit Application?:
Does your item contains one of the following?:
Total Price:
Bill to:
Pickup or Delivery?:
Pick-Up Date:
Pick-Up Address:
Product Description:
Product Type:
Product Weight:
COD (Cash on Delivery) required?:
COD (Cash on Delivery) Amount:
Receiver Information
Name:
House / Unit No:
E-mail:
Phone Number:

Charges Details

Delivery Type:
Amount to be paid:
Paying Patient:
Payment Method:
Remarks:

I acknowledge that all the information provided above is true and correct.
I have read and agree to the Terms and Condition.

Terms and Condition

[[ms]]Saya mengakui bahawa ubat saya hanya akan sampai dalam masa 5-7 hari bekerja untuk penghantaran standard selepas Go Rush menerima ubat daripada Farmasi.[[en]]I acknowledge that my medication will only arrive within 5-7 working days for standard delivery after Go Rush receives the medication from Pharmacy.

[[ms]]Saya mengakui bahawa ubat saya hanya akan sampai dalam tempoh 2-4 hari bekerja untuk penghantaran ekspres selepas Go Rush menerima ubat daripada Farmasi.[[en]]I acknowledge that my medication will only arrive within 2-4 working days for express delivery after Go Rush receives the medication from Pharmacy.

[[ms]]Saya mengakui bahawa ubat saya hanya akan sampai dalam masa 3 jam untuk penghantaran segera selepas Go Rush menerima ubat daripada Farmasi.[[en]]I acknowledge that my medication will only arrive within 3 hours for immediate delivery after Go Rush receives the medication from Pharmacy.

[[ms]]1 Nombor Bru-HIMs = 1 Caj[[en]]1 Bru-HIMs Number = 1 Charge

[[ms]]Mengikut Terma dan Syarat[[en]]Terms and Conditions Applied*

I acknowledge that all the information provided above is true and correct.
We are not liable for any damages to the items that has been shipped and arrived in Brunei.
I agree with the estimated delivery date of my parcel which will arrive in Brunei at least 10 working days.

Thank you!
We have received your request order.
Your tracking number will be
Tracking number

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