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Prescription Request Form

  • This is Costco Japan on-line prescription order.
  • You can send prescription images beforehand to receive your medications smoothly.
  • Pharmacist will contact you if your medications are need to order due to out of stock.
  • Prescription is valid for 4 days from date of issue.
  • We also welcome Non-members for prescription service.

Confirm of content

  • Request is NOT completed yet.
  • Please confirm that all your details are correct as below. When ready, click "Submit" button.
Take Photo or Select Picture from folder(*) 
How to select multiple images
  PC: Click the file while holding down the Ctrl key
  SmartPhone&Tablet: Take a photo breforehand and select from the album
*Depending on your smartphone, you may not be able to select multiple images.
Name of Applicant(*)

Pick up at(*)
Do you prefer Generic medicine?(*)
Do you have prescription note?(*)
Date for Pick Up(*)
Time for Pick Up(*)
Phone #(*)

Email Address(*)
Email Address(confirmation)(*)
If patient is children, please enter weight for dosage

kg
Comment
Take Photo or Select Picture from folder(*)

Name of Applicant(*)

Pick up at(*)

Do you prefer Generic medicine?(*)

Do you have prescription note?(*)

Time for Pick Up(*)

Phone #(*)

Email Address(*)

If patient is children, please enter weight for dosage

Comment 

                        

                    

                    
                        (*)…Required


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