REQUEST A PRESCRIPTION
ARE YOU AN EXISTING OR NEW PATIENT?
*
I am a new patient (I HAVE NOT ordered prescriptions from Click Clinic before)
I am an EXISTING PATIENT ( I HAVE ordered prescriptions from Click Clinic before)
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PATIENT NAME
*
Prefix
First Name
Last Name
DATE OF BIRTH
*
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Day
-
Month
Year
MOBILE PHONE NUMBER
*
Please enter a valid mobile phone number. DO NOT INCLUDE COUNTRY CODE!
ADDRESS
*
Street Address
Suburb
State
Post Code
PATIENT EMAIL
*
example@example.com
MEDICARE NUMBER (if any)
MEDICARE REFERENCE NUMBER
The number in front of your name on your medicare card
MEDICARE EXPIRY DATE
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Day
-
Month
Year
Date
ANY ALLERGIES?
*
Yes
No
Please detail EVERYTHING you are allergic to and what reaction you have
*
Detail all allergies
HAVE YOU STARTED, CEASED OR CHANGED MEDICINES SINCE YOUR LAST PRESCRIPTION FROM US?
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Yes
No
DETAILS OF MEDICINE CHANGES
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Please provide full details of all medicine changes since your last prescription from Click Clinic
WHAT MEDICINES ARE YOU TAKING?
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Please list ALL the medications you are taking, including herbal, prescription, and any over the counter medicines
Since your last click clinic prescription, have you developed any new medical problems?
Yes
No
PLEASE DETAIL ALL YOUR MEDICAL PROBLEMS / DIAGNOSES
*
PRESCRIPTIONS REQUIRED
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Medicine Name
(please use generic name if known)
eg Valsartan
Strength & form
eg 80mg tablet
Dose
eg 1 tablet
Frequency & timing
eg once a day in the morning
Why do you take this medicine?
eg high blood pressure
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2
3
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UPLOAD A PHOTO OF YOUR LAST PRESCRIPTION OR PHARMACY LABEL
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ANY RELEVANT MEASUREMENTS? (eg blood pressure, height, weight, blood sugar...)
UPLOAD A PHOTO OF YOUR ID (MEDICARE CARD / PASSPORT / DRIVER LICENCE)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
HOW DO YOU WANT TO GET YOUR MEDICINES
*
DELIVER MY MEDICINES TO ME anywhere in Australia by Click Clinic's national partner pharmacy Ace pharmacy
Pick-up medications from a pharmacy I choose (If Medicare details provided, an e-prescription will be sent to you by SMS, otherwise script will be sent to the pharmacy)
DETAILS OF PHARMACY
*
Pharmacy Name
Street Address
Suburb
State
Post Code
PAYMENT
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Prescription request
$
30.00
AUD
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
SUBMIT
Date & Time submitted
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Should be Empty: