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
2 digit day, 2 digit month, 4 digit year
Address

Street Address

Street Address Line 2

CityState / Province

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

Provision of Packs
Frequency of Packs

Other
Prescriptions are obtained from doctor by:

Other
Medication Summary from doctor (file)

Cancelof
Medication Summary (photo)
Preferred Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearRegular 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)

Rows	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

I want to sign the information and consent form
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

Signature using mouse / finger
Name of signatory

First NameLast Name
Should be Empty: