InstaPharmacy - Order Form

Place Your Medicine Order

Customer Name*

Mobile Number*

Full Delivery Address*

Pincode*

Medicine Name(s) (Optional if prescription uploaded)

Upload Prescription Image*

Click to Upload Prescription

JPG, PNG, or PDF • Max 5MB

✓ Accepted by licensed pharmacies

Payment Method*

I confirm that the prescription provided is valid and issued by a registered medical practitioner. I understand that medicines are sold and dispensed by licensed pharmacies and InstaPharmacy only facilitates ordering and delivery.

Your data is protected with SSL encryption • Orders processed by licensed pharmacies

Order Confirmed!