Client Service Request Form

Please fill in all required information accurately. This form helps us understand your needs and deliver customized pharmaceutical business consultancy services.

📝 NB: Your information is confidential

1. CLIENT INFORMATION

Full Name *

Organization/Pharmacy Name *

Type of Business *

Community Pharmacy

Wholesale

Import

Other

National ID *

TIN Number *

Location (District/Sector) *

Phone Number *

Email Address *

Preferred Mode of Contact *

Phone

3. PREFERRED TIMELINE

When do you need the service? *

Urgently

Within 7 days

Within 1 month

Any specific dates in mind?

4. BRIEF DESCRIPTION OF YOUR NEEDS

Please describe in 2–5 sentences what kind of support you are requesting and the current status of your pharmacy or business idea: *

5. INSURANCE PARTNERS

RSSB, MMI, SANLAM, UAP, RADIANT, BRITAM, PRIME, EDEN CARE, ETC

If you are buying or selling a pharmacy, you can also specify which insurance partners you would like to work with.

6. PAYMENT & BILLING INFORMATION

Will you require a quotation/invoice before service? *

Yes

Preferred payment mode *

Bank Transfer

Cash

Mobile Money (MoMo)

Business registered name for invoicing (if applicable)

7. DECLARATION

I declare that the information provided above is true and complete to the best of my knowledge. I understand that service delivery will begin once an agreement is signed and initial payment is made as per the consultancy terms.

I accept the declaration above *

Digital Signature (Type your full name): *

Date:

1. CLIENT INFORMATION

2. SERVICES REQUESTED (Tick all that apply)

3. PREFERRED TIMELINE

4. BRIEF DESCRIPTION OF YOUR NEEDS

5. INSURANCE PARTNERS

6. PAYMENT & BILLING INFORMATION

7. DECLARATION