Special Order

These are all items in use by Hospitals that are not in our Price Catalogue.

Customer Information

Your Name *

E.g: Fatuma Shaaban

Hospital/Dispensary Name: *

E.g: Muhimbili National Hospital

P. o. Box: *

District *

Region: *

E-mail: *

False email will invalidate your request.

Tel: *

Fax (Optional):

How do you want us to contact you?

Tick all that apply.

Contact options *

By Phone

By Email

By Mail(P. o. Box)

Special Order Details

Please try to explain explicitly about your order(Try to be specific)

Product/Item Name: *

Product Description or Specification *

Please try to avoid generic specifications

Additional Information

Attach file (Optional)

If you have got a document or image that can help us meet your request please attach here. Allowed extensions:- pdf, xls, xlsx, doc, docx, gif, jpg, png (Maximum file size: 1MB)

Word verification * Type the characters you see in this picture.

(verify using audio)

Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.

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Special Order

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