Online Prescription Application
Full Name
*
First Name
Last Name
Date of birth
*
/
Day
/
Month
Year
Address
*
Street Address
Street
Suburb
State / Province
Post Code
Email
*
example@example.com
Phone Number
*
Are you an existing Inner North Medical Clinic patient?
Please Select
Yes
No
Are you a Medicinal Cannabis patient?
Please Select
Yes
No
Name of your Inner North GP
Authority Required Prescriptions Declaration
*
Please Select
I agree with the terms
I have read the terms regarding Authority Required Prescriptions. These medicines aren’t available through this service. Refunds for such requests take 1-2 weeks to process and incur a 1.8% non-refundable fee.
Medication #1 Name & Dosage
*
Medication #2 Name & Dosage
Medication #3 Name & Dosage
Medication #4 Name & Dosage
Medication #5 Name & Dosage
Medication #6 Name & Dosage
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Inner North Medical Repeat Script – Max 6 per application
$
65.00
AUD
Pay With Credit Card
Submit Your Application
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