Script Request Form

First Name *

Last Name *

Date of Birth *

I have an Australian Medicare Card

YesNo

Medicare Card Number (10 digits) *

Medicare Card Reference (Number before patient name) *

Medicare Card Expiry *

The script fee for non-Medicare patients is $47.

Scripts will only be able to be sent via Post. E-scripts (SMS and Email) are unavailable without a valid Medicare number.

Email Address *

Mobile Number *

I am a patient of: *

I agree for my card entered below to be charged the script fee of $42 prior to my scripts being issued. *

I agree for my card entered below to be charged the script fee of $47 prior to my scripts being issued. *

I acknowledge my request may not be granted upon review of my file by my doctor and an appointment may be required (in such case, the script fee will be refunded). As per the Medical Board of Australia guidelines, a repeat script may not be able to be issued without a real-time direct consultation: "it is only appropriate for your usual medical practitioner or another health practitioner with access to your clinical record to prescribe without a consultation in certain circumstances." *

Scripts Required: (A maximum of 3 items can be requested at one time)

Script #1: *Please included the strength of medication (EG: Meformin XR 500mg)

Script #1 Delivery Method *

E-script as SMS (will be sent to the number provided above)E-script as email (will be sent to the email provided above)Send my script to my compounding pharmacy (will be sent to the details entered below)Send my script to my postal address

Script #1 Delivery Method No Medicare *

Send my script to my compounding pharmacy (will be sent to the details entered below)Send my script to my postal address

Compounding Pharmacy Details (Script #1) *

Compounding Pharmacy Name *

Compounding Pharmacy Address *

Street address *

City *

State *

Postcode *

Compounding Pharmacy Contact Number *

Compounding Pharmacy Email and/or Fax *

Please click here if you want to request a second script.

Script #2 *Please included the strength of medication (EG: Meformin XR 500mg)

Script #2 Delivery Method *

E-script as SMS (will be sent to the number provided above)E-script as email (will be sent to the email provided above)Send my script to my compounding pharmacy (will be sent to the details entered below)Send my script to my postal address

Script #2 Delivery Method No Medicare *

Send my script to my compounding pharmacy (will be sent to the details entered below)Send my script to my postal address

Compounding Pharmacy Details (Script #2) *

Compounding Pharmacy Name *

Compounding Pharmacy Address *

Street address *

City *

State *

Postcode *

Compounding Pharmacy Contact Number *

Compounding Pharmacy Email and/or Fax *

Please click here if you want to request a third script.

Script #3 *Please included the strength of medication (EG: Meformin XR 500mg)

Script #3 Delivery Method: *

E-script as SMS (will be sent to the number provided above)E-script as email (will be sent to the email provided above)Send my script to my compounding pharmacy (will be sent to the details entered below)Send my script to my postal address

Script #3 Delivery Method No Medicare *

Send my script to my compounding pharmacy (will be sent to the details entered below)Send my script to my postal address

Compounding Pharmacy Details (Script #3) *

Compounding Pharmacy Name *

Compounding Pharmacy Address *

Street address *

City *

State *

Postcode *

Compounding Pharmacy Contact Number *

Compounding Pharmacy Email and/or Fax *

Additional Comments (Optional)

Payment Details:

Script Payment Fee *