Script Request

"*" indicates required fields

First name:*

Last name:*

Date of Birth:*

Please enter your date of birth in the format DD/MM/YYYY

Mobile Phone:*

Email:*

How would you like this repeat prescription delivered?*

I would like an e-prescription sent to me via SMS (text) – $25

I would like an e-prescription sent to me via email – $25

I would like to collect a hard copy – $25 (please note scripts cann’t be posted)

Please enter as much information as possible

Name of Medication:*

Dosage:

Repeat Prescription Request – Important Information. Please read carefully before submitting your request.

This service is only available to existing patients of the practice.
We can only provide repeat prescriptions for medications previously prescribed to you by your doctor.
You may select more than one medication with each request.
Repeat prescriptions for addictive medications, including benzodiazepines and opiates, are not provided through this service.

Each request is reviewed by your GP and approved or declined on clinical grounds.
If your request is declined, you will be advised to make an appointment.
Your GP may not be able to issue a repeat prescription if you have not been seen within the last 6 months.

Please sign:*

Todays Date:*

office use only:

request approved

request declined

appointment required