Repeat Prescription Request

Your details

First name (REQUIRED)

Last name (REQUIRED)

Street address (REQUIRED)

Suburb (REQUIRED)

Post code (REQUIRED)

Mobile or work phone (REQUIRED)

Email address (REQUIRED)

Confirm email (REQUIRED)

For the attention of (required)

—Please choose an option—Dr Samira PotturiDr Frank TrapnellDr Andrew ThompsonReceptionPractice Manager

Your Prescriptions

How many different prescriptions do you need? (REQUIRED)
123

When do you require your prescription? (REQUIRED)
—Please choose an option—Within 2 Hours ($25)Within 24 Hours - Authority Prescription ($15)Within 24 Hours - Non-Authority Prescription ($10)

Are you prepared to have your prescription sent to your mobile telephone? (REQUIRED)
—Please choose an option—Yes (I would be happy to receive my prescription by text knowing applicable fees will still apply)No (I would prefer to have a printed/paper copy of my prescription which I will collect from the clinic - additional fees will apply if mailing, or faxing my prescription)

How would you like to be contacted when your prescription is ready? (REQUIRED)
TelephoneEmail

First Prescription
Medication name (correct spelling) (REQUIRED)

Dose/Strength (mg/mL/mcg) (REQUIRED)

How often do you take this medication? (eg twice per day or once per week etc.) (REQUIRED)

For what condition was this medication prescribed? (REQUIRED)

Please Note

Payment, shown below, is an indication only. Payment must be made at the time of collection of your prescription. Payment can be made by cash, Eftpos or Credit card.