Order Disini - Borang Pesanan Secara Online

Sila isi borang ini dan hantar slip pembayaran bersama borang ini sebagai bukti anda telah membuat bayaran secara online Borang Pesanan Ubat Homeopati Secara Online Nama Pembayar:.......................................................................... Alamat Pos.................................................................................. ................................................................................................... ................................................................................................... Tel Rumah...........................H/P/Mobile..................................... Pesanan ubat ( Sebutkan nama ubat ) .................................................................................................. Sila bayar terus kedalam account: Dr Che Zaharah binti Loman Bank Simpanan Nasional Acc No: 14118-29-83224486-5 Jumalah Pembayaran RM................................................ Tarikh:..............................Tanda tangan pembeli.................................. Sila poskan slip pembayaran bersama borang ini kepada Dr Hajjah Zaharah bt Loman d/a Pusat Perubatan Homeopathy Dr Nik Omar 122 Taman Universiti, Kg Gelang Mas, Meranti, 17010 Pasir Mas, Kelantan. Sila maklum kepada kami setelah membuat pembayaran dengan telifon terus kepada kami:- Tel: 019-9921218 Dr Zaharah Tel: 09-7972948 Klinik Tel: 019-9401915 Prof Dr Nik Omar
Borang Aduan Persakit Tarikh:................... Nama Pesakit:............................................................................ Alamat Pos:................................................................................ .................................................................................................. .................................................................................................. .................................................................................................. I/C...................................................Umur.................................. No Tel:.................................(rumah)........................................HP Aduan atau Gejala Kesakitan ( Sila ceritakan panjang lebar tentang masalah yang dihadapi) ................................................................................................... ................................................................................................... ................................................................................................... Sila tambah kertas lain jika perlu. Tandatangan pesakit:....................................................................