Online Payment Form

Online Prescription Request Service

Belmont Medical Practice
Are you a patient of Belmont Medical Practice?

YesNo
Online Request Details
Please complete this form so that we can evaluate your request and then email you a valid prescription. We can only provide this service if you are a current patient of this practice. A service fee of $60 will be charged if you hold a valid medicare card. If you do not have a valid medicare card a service fee of $110 will be charged.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Phone number*
Phone number
Email*
example@example.com.au
Do you currently have Medicare?*

YesNo
Name of Medication*
Strength and frequency of Medication*
e.g 250mg twice a day
Reason for the prescription*
Practice policy

This service will incur a service fee of $60 if you have a vaild medicare card. Otherwise this service will incur a service fee of $110.

Your credit card will not be debited until your service is completed.

If services are not provided there will be no charge to your credit card.

Services Fee*

Patient with Medicare

Service Payment - Out-of-pocket FeeThe fees will be deducted after service. This is an Out-of-Pocket Fee with no Medicare Rebate.

$60.00AUD

Patient WITHOUT Medicare

Full Fee for Service The fees will be deducted after your consultation. Receipt for private health claiming will be provided to your email.

$110.00AUD

Total

$0.00AUD

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Online Prescription Request Service