Prescription Renewal

1
Have you had an appointment with Restorative Health Clinic before?* This field is required.If you’ve seen one of our practitioners—either in person or via Telehealth—you’re considered a current patient.
YESNO
2
What's Your Name?* This field is required.Please enter your full name so we can locate your file and renew your prescription accurately.
First Name
Last Name
3
Date of Birth* This field is required.We use your date of birth to verify your identity and ensure your prescription details are accurate.
Day
Month
Year
4
Have you had an appointment within the last 12 months?* This field is required.If you haven’t had a consultation with us in the past 12 months, you’ll need to book a short review appointment so we can ensure there have been no health changes and continue to provide safe, appropriate care. If you proceed with purchasing a script and haven’t had an appointment with us in the past 12 months, you’ll be booked for a short phone consultation.
YESNO
5
Have you started, stopped, or changed any of your medications since your last prescription from Restorative Health Clinic?* This field is required.Let us know if anything has changed so we can safely renew your prescription and update your records.
YESNO
6
Have you been diagnosed with any new medical conditions since your last prescription from Restorative Health Clinic?* This field is required.Tell us if there have been any new health issues so we can make sure your prescription is still safe and appropriate.
YESNO
7
Which prescription/s would you like to renew?* This field is required.Use a separate row for each medication. For injectable medications: Please specify the number of units per injection, whether this dose is sufficient, and how long each dose lasts.
8
Who did you see at your most recent appointment?* This field is required.Knowing who you saw last helps us review your notes and keep your care consistent.
Kate Ternahan
Michaela Walters
Tina Crosbie
Melissa Hadley Barrett
Cindy Owen
9
What’s your mobile number?* This field is required.We’ll securely deliver your renewed prescription to your mobile phone.
Country Code
Phone Number
10
What's Your Email Address?* This field is required.We’ll securely deliver your renewed prescription to your email address.
example@example.com
11
Which pharmacy should we send your renewed prescription to?* This field is required.
Oxford Compounding (North Perth, WA)
Perth Compounding Suites (Mount Lawley, WA)
Other Pharmacy
12
Your prescription will be automatically sent to Perth Compounding Suites (PCS) and you will be contacted within 24-hours to arrange payment and delivery.Want to know why we use PCS? See the FAQ on our website.
13
Your prescription will be automatically sent to Perth Compounding Suites (PCS) and you will be contacted within 24-hours to arrange payment and delivery.

Want to know why we use PCS? Please click here to see the FAQ on our website.
14
What's your preferred pharmacy's contact information?* This field is required.
Pharmacy's Name
Pharmacy's Email
Pharmacy's Address
15
Confirm and pay for your prescription renewal* This field is required. Your $30 AUD payment includes a clinical review of your prescribed medication by a licensed Nurse Practitioner to ensure your treatment remains safe and effective. Payments are securely processed using encrypted technology via Stripe.
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ORDER SUMMARY
Total costAUD
Prescription Renewal
$30.00 AUDEdit
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Total cost $0.00 AUD
First Name
Last Name
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How easy was this form to complete?Slide to rate your experience—from frustrating to effortless. Your feedback helps us improve.
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Please verify that you are human* This field is required.To protect your privacy and data, we use secure verification. No action needed unless suspicious activity is detected.
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