Prescription request form
Please complete this form for a prescription request from a Leading Steps Paediatrician. The Paediatrician must have previously seen the child and a future appointment needs to be already booked. This service is to be used if there is an unexpected need for a prescription. For stimulant medications for ADHD, the last prescription must be expiring within the month (government requirement.) By using this service you consent, if required, to a video consult, to clarify any details of the clinical progress of your child. There will be an attempt to process this request within 2-5 business days. In most cases the paediatrician will write the script to provide enough medication to last until the next review appointment. At times the doctor will need to further investigate the request and a script may not be able to be provided. The usage of this service will incur a $30 cost. Please first check with the pharmacy that there are no repeats left.
Patients Full Name
*
First Name
Last Name
Child's date of birth
-
Month
-
Day
Year
Date
Parents name
*
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Paediatrician
Please Select
Dr Dylan Wilson
Dr Naomi Chellew
Dr Stephen Ansley
Dr Garth Small
Dr Melanie Aldridge
Dr Glenn Harte
Dr Scott Blundell
Dr Catherine Stewart
Dr Syed Fasihullah
Dr Mike Wong
Dr Sarah Taylor
Dr Amy Whittaker
Dr Tim Pont
Dr David Pincus
Dr Victoria Matheson
Dr Ananya Patheja
Dr Natasha Russell
Dr Sophia Knoblanche
Dr Prudence Verry
Prof Lionel Lubitz
Dr Ravi Bala
Dr Elize O'Reilly
Dr Diane Jensen
Unknown (can not recall)
Prescription required
*
Dose
*
Frequency medication is taken
*
Current weight and height (if known)
Comments
0/150
Should be Empty: