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Winnipeg Homoeopathic Clinic

Unit 101 - 1383 Pembina Hwy.
Winnipeg, Manitoba
R3T 2B9

Tel: (204)284-7778, Fax (204)284-9997
e-mail: info@drkumarhomeopathy.com

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Homoeopathic Medicine Order Form
* Indicates Required Fields

Address Information
First Name:*
Last Name:*
Address:*
City:*
State/Province:*
Country:*
Zip/Postal Code:*
Phone Number:*
Email Address:*

Prescription
Are you sending a NEW prescription or a REFILL request to be processed with this order?


Special Instructions
Preferred method of contact for clarification:   Email Telephone
Preferred method of contact for processing:   Email Telephone
Preferred method for payment:   Credit card Cash*
  * Cash payment is only accepted for instore pickups and refills


Refills Requested

* - Fields required to be filled for your request.
  • Medication Name:as on label, indicated liquid or pellet form (ex. Arnica pellets)
  • Potency:e.g. 1DH, 6C, 30C, 200CH, 1M, 5M, 10M, etc.
  • Quantity:number of bottles of each remedy
  • Brand:Heel, Boiron, Dolisos, Metagenics, etc.
*Medication Name: Potency: *Quantity: Brand: Size:

Please be advised that if the quantity requested does not correspond with our pack sizes, we will fill according to your most recent order, or the closest available pack size.

The order you have just submitted will for processing and cannot be changed or stopped once submitted. Please be sure all information you have provided is accurate. A representative will contact you within 2 hours during regular business hours. Please allow up to 2 days for delivery of your order.

Free shipping on Canadian orders over $100 (excludes shipping address in the USA).