Pharmacy Support Service
Authorised Pharmacist/Technician Name
*
First Name
Last Name
Pharmacy Name
*
Legal name of pharmacy/chemist
Pharmacy/Chemist EDI
Healthlink EDI mailbox
Pharmacy Prescription 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
General Practitioner Name
*
Patient's enrolled GP
GP Clinic Name
*
GP Healthlink EDI
*
Request Repeat Rx:
State your repeat prescriptions, one item per line
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Browse Files
Drag and drop files here
Choose a file
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of
Submitted electronically
Toniq Extract
Latest Laboratory results review
Concerns raised
No concerns raised
Not checked
Blister pack required
Yes
No
N/A
Preferred chemist/pharmacy
*
Which pharmacy this script will be sent to.
Health Info
Over the last week, have you been feeling unwell that you need to see a doctor?
*
Yes
No
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
Service fees (will be invoiced back to Pharmacy)
*
Initial Request
No change request
Subsequent request with changes
Urgent request
T&C agreement
By submitting this request for prescription, as the pharmacist , you can confirm that the patient health information is true and that you have confirmed that the patient has consented to share their health information as per the Terms for Services Agreement as published online (www.awc.net.nz). Medications with expired Special Authority will not be renewed.
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