Travel Letter Request

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First name:*

Last name:*

Date of Birth:*

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

Mobile Phone:*

Letter delivered?*

I understand the travel letter will be emailed to the email address on my file – $25

Travel Details (please enter the total duration of travel):*

Medications and Supplements*

Please list all prescription medication, over the counter medicines and supplements you are taking with you.

Travel Letter Request – Important Information. Please read carefully before submitting your request.

This service is only available to existing patients of the practice.
Travel letters are issued at the discretion of your doctor and must be clinically appropriate.

You may be required to book an appointment (telehealth or in-person) prior to the letter being issued.
The letter will list the medications and/or supplements currently prescribed.

Please sign:*

Todays Date:*

Your request will only be processed once payment has been successfully completed. Requests without completed payment will not be actioned.

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Travel Letter Request*

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