Prescription request form
Please complete this form for a prescription request from a Leading Steps Paediatirician. 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. A prescription fee of $15 will be charged for this service. 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 3-5 business days. The usage of this service will incur a $15 cost.
Patients Full Name
*
First Name
Last Name
Date of birth
*
Parents name
*
Phone Number
*
Email
example@example.com
Paediatrician
*
Prescription required
*
Dose
*
Frequency medication is taken
*
Comments
0/150
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