Repeat Prescription Request

Only current patients of Kingsley Medical may request a prescription renewal. All prescriptions must be collected. Prescriptions will NOT be faxed or mailed.

 

Your details

First name *

Last name *

Street address *

Suburb *

Post code *

Mobile or work phone *

Email address *

 

Your Prescriptions

How many different prescriptions do you need? *
123

When do you require your prescription? *

How would you like to be contacted when your prescription is ready? *
TelephoneEmail

First Prescription
Medication name (correct spelling) *

Dose/Strength (mg/mL/mcg) *

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

For what condition was this medication prescribed? *

Other instructions to your doctor


Second Prescription
Medication name (correct spelling) *

Dose/Strength (mg/mL/mcg) *

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

For what condition was this medication prescribed? *

Other instructions to your doctor


Second Prescription
Medication name (correct spelling) *

Dose/Strength (mg/mL/mcg) *

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

For what condition was this medication prescribed? *

Other instructions to your doctor


Third Prescription
Medication name (correct spelling) *

Dose/Strength (mg/mL/mcg) *

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

For what condition was this medication prescribed? *

Other instructions to your doctor

 

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.

 

Total - $25.00

Total - $15.00

Total - $10.00