Medication Pack Expression of Interest

Medication Pack Expression of Interest

New MedicoPak Patient Information Form
SuperPharmacyPlus uses the latest in robotic technology to pack these MedicoPaks, ensuring greater accuracy, safety and convenience for you. Many of our customers have found blister pack medication has helped them to effectively manage their medications and has made medication calculation much easier. For those with busy lifestyles blister pack medication can make travelling with medication much more manageable.

Cost: $5/week OR $15/4 weeks

Please fill out the following form to get started, or talk to one of our pharmacists today!
Name

First NameLast Name
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Phone (Mobile)
Phone (Home)
If preferred
Email
example@example.com

Packing Information
Provision of Packs

Picked up from SuperPharmacyPlus (Stafford)Delivered to my address (charges applicable)
Frequency of Packs

Weekly ($5)Fortnightly ($10)Monthly (4 Weeks)($15)Other
Prescriptions are obtained from doctor by:

Electronic Prescription (to pharmacy)Obtained by patient and provided to pharmacyOther
Medication Summary from doctor (file)

Cancelof
Medication Summary (photo)
Preferred Start Date

DayMonthYear
Regular packs will commence on a MONDAY. **Please note that all prescriptions, tablets and other supplements to pack would need to be provided to the pharmacy at least 2 business days prior to this date**

Medications to pack (manual)

	Medication	Directions	Time of Day taken (Options: Pre-Breakfast / Morning / Lunch / Dinner / Bedtime
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Other

Terms and Conditions
I want to sign the information and consent form*

Digitally eSign securelyDownload and sign paper copy (see below)
Download Link (hardcopy to sign and submit to pharmacy manually)
Download DAA Information and Consent Form
DAA Information and Consent. Please sign both the below document (which is required for the Australian Government) as well as the signature at the bottom of the page.
Signature*

Clear
Signature using mouse / finger
Name of signatory

First NameLast Name
Should be Empty: