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Pharmacy visits
1
Security Code
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2
: المحافظة
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الشمال
العاصمة
البلقاء والأغوار الوسطى
الجنوب
(الشرق(الزرقاء
الشمال
العاصمة
البلقاء والأغوار الوسطى
الجنوب
(الشرق(الزرقاء
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3
:صيدليات محافظات الشمال
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4
:صيدليات محافظات الجنوب
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5
:صيدليات محافظة العاصمة
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6
: (صيدليات محافظة الشرق (الزرقاء
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7
: صيدليات محافظة البلقاء والأغوارالوسطى
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8
Visit Type
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Order
Payment
Samples
Account Statement
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9
Select products
*
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Honix Ointment
BioActive BioGene
BioActive Omega 3
BioActive Folic Acid
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10
Payment Type (Pre)
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Credit
Cash
Check with order
Credit
Cash
Check with order
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11
Honix Ointment
Honix 15 g \Order
Honix 15 g \Bonus
Honix 30 g \Order
Honix 30 g \Bonus
Honix 70 g \Order
Honix 70 g \Bonus
Honix Feedback
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12
BioActive BioGene
BioActive BioGene \Order
BioActive BioGene \Bonus
BioActive BioGene Feedback
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13
BioActive Omega 3 Plus
BioActive Omega 3 Plus 120ml / 1500 \Order
BioActive Omega 3 Plus 120ml / 1500 \Bonus
BioActive Omega 3 Plus Feedback
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14
BioActive Folic Acid
Folic Acid Tablet 400 mcg 90' \Order
Folic Acid Tablet 400 mcg 90' \Bonus
BioActive Folic Acid Feedback
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15
Payment Type (Post)
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Cash
Check
Cash
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16
القيمة / Value
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JOD
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17
رقم الوصل/السند
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18
رقم الشيك
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19
تاريخ الإستحقاق
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-
Date
Year
Month
Day
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20
Account Statement
*
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YES
NO
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21
Samples
*
This field is required.
Honix Ointment
BioGene
Omega 3 plus
Folic Acid
Honix Ointment
BioGene
Omega 3 plus
Folic Acid
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22
Visit Note
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23
Visit Rate
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1
2
3
4
5
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