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DIABETIC ORDER FORM
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FULL NAME
*
Your answer
PHONE NUMBER
*
Your answer
DELIVERY ADDRESS
*
Your answer
CITY/PROVINCE/STATE
*
Your answer
CHOICE DATE OF DELIVERY
*
MM
/
DD
/
YYYY
COUNTRY CHOICE PACK
*
GHANA: 1,100GHC
ZAMBIA: 2,650KWACHA
KENYA: KES16,000
UGANDA: 450,000UGX
NIGERIA: N55,500
TANZANIA: 300,000TZH
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