Epipen script request for Patients
Please note that this request can only be completed if the patient has been assessed at our clinics within the last 12 months. The script will be emailed and posted to the address you provide. A fee of $45 is payable if this request is outside of a consultation - Reception will contact you to arrange payment with thanks.
Patient Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Parent or Guardian Name (if applicable)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Email
*
example@example.com
Phone number
*
Please indicate your doctor at Compass Immunology or Compass Kids Clinic
*
Dr Kate Bonehill
Dr Katharine Foster
Dr David Heyworth-Smith
Dr Carl Kennedy
Dr Susan Perel
Dr Babu Philip
Dr Zi Tan
Dr Elize O'Reilly
Dr Sophie Willcocks
Dr Kim Robertson
Dr Mariana Melo
Dr Kathryn Heyworth
Dr Venetia Whitehead
What are your allergies?
*
When was your last allergic reaction? (Please leave blank if no reactions in the last 12 months)
-
Day
-
Month
Year
Approximate weight in kilograms
*
Do you have a review appointment date?
*
Yes
No
Do you have a current Anaphylaxis Action Plan?
*
Yes
No (Please also complete the Request for Action Plan for Anaphylaxis form)
Reason for script request
*
Epipen has expired
Epipen has been lost or damaged
Epipen used for anaphylaxis episode
Need more than two Epipens for school, family (NB these will be private scripts)
How would you like to receive the script?
SMS
Email
Post
Pick up at reception Greenslopes
Pick up at reception Grange
Pick up at reception Birtinya
Any other comment
Submit
Should be Empty: