Repeat Prescription Support Service
GP Name
First Name
Last Name
Clinic Name
GP Practice
Clinic EDI
Healthlink EDI mailbox
Clinic Email Address
example@example.com
Date
-
Day
-
Month
Year
Date
Patient Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Patient's Date of Birth
Gender
Please Select
Female
Male
Gender diverse
Unspecified
NHI
Patient Email
example@example.com
Mobile Phone
-
Area Code (0x/02x)
Phone Number
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
Request Repeat Rx:
State your repeat prescriptions, one item per line
Supply period
10 Days
One Month
Three month
Preferred chemist/pharmacy
Which pharmacy this script will be sent to.
For GP2GP use EDI aratakwc
Medications
Allergies
Inbox
Classifications
Health Info
Latest BP
e.g. 120/70
Latest BP Date
-
Day
-
Month
Year
Date of BP taken
Current weight
e.g. 70kg
Latest weight taken
-
Day
-
Month
Year
Date of Weight taken
Previous Weight
e.g. 60kgs
Previous weight taken
-
Day
-
Month
Year
Date of previous weight
T&C agreement
By submitting this Request for Prescription , you agree to the Terms fo Service Agreement as published online.
Submit
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