Online Payment Form

Online Prescription Request Service

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

YesNo
Apologies. We can only provide online prescriptions for existing patients.
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 $50 will be charged if you hold a valid medicare card. If you do not have a valid medicare card a service fee of $95 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 $50 if you have a vaild medicare card. Otherwise this service will incur a service fee of $95.

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.

$50.00AUD

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.

$95.00AUD

Total

$0.00AUD

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Online Prescription Request Service