Order Form

The order is not submitted yet.
Please click "Agree & Submit" after confirming your details and agreeing to the terms and conditions below.
A tracking number will be sent once the order is submitted.

The tracking number and notification updates on the order status will only be provided if the user have:
1) Provided their correct active phone number
2) Installed WhatsApp
3) Updated WhatsApp to the latest version

The order will only be processed during working hours.

Order Summary

Personal Details

Full Name:

House / Unit No:

E-mail:

Phone Number:

Additional Phone Number:

Product Details

Product Type:

Patient's Number:

Patient's Date of Birth:

IC-Number / Passport:

Health Centre:

Parcel Tracking Number:

Go Rush Receiving Country:

Shipment Method:

E-Commerce Name:

Commodities:

Currency:

Weight (KG):

Permit Application?:

Does your item contains one of the following?:

Total Price:

Bill to:

Pickup or Delivery?:

Pick-Up Date:

Pick-Up Address:

Product Description:

Product Type:

Product Weight:

Receiver Information

Full Name:

House / Unit No:

E-mail:

Phone Number:

Original Tracking Number:

Courier:

Item Description:

Quantity:

Total Amount (RM):

Charges Details

Delivery Type:

Delivery Duration:

Amount to be paid:

Paying Patient:

Payment Method:

Remarks:

I acknowledge that all the information provided above is true and correct.
I have read and agree to the Terms and Condition.

Terms and Condition

Order form under maintenance....

Order Form

Personal Details

Product Details

Item Details

Receiver Information

Item Details

Charges Details

Order Summary

Personal Details

Product Details

Receiver Information

Charges Details