MedDirect Enrolment Request

1
Are you enrolled with WeCare?* This field is required.MedDirect is only available to patients who are enrolled with WeCare. If you’re not enrolled, we’ll let you know how to enrol next.
Yes
No
2
Name* This field is required.
First Name
Last Name
3
Date of birth* This field is required.
Date
Day
Month
Year
4
What was your sex at birth?* This field is required.
Male
Female
Prefer not to say
5
NHI number (if you know it)
6
Home address* This field is required.
Street name and number
Suburb
City
Region
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Best contact phone number* This field is required.
Please enter a valid phone number.
8
Email address* This field is required.
example@example.com
9
Which WeCare clinic do you usually go to?* This field is required.
Please Select
Please Select
WeCare Wigram
WeCare Lincoln
WeCare Ilam
WeCare Faringdon
10
Please confirm the following* This field is required.
I consent to Pharmacy Now delivering my regular medications
I understand MedDirect is for stable, long-term medication only
I agree to tell WeCare if my condition, symptoms, or medications change
I consent to my MedDirect care being provided with virtual GP oversight
11
Your regular medications* This field is required.Please list all the medications you take regularly
12
Would you like to request any “as needed” medications you’ve had prescribed before?This form cannot be used to request new medications. All requests are reviewed and approved at the clinician’s discretion.
Paracetamol (for mild pain or fever)
Ibuprofen (for pain or inflammation)
Naproxen (for pain or inflammation)
Cetirizine (for allergies)
Loratadine (for allergies)
Fluticasone nasal spray (for hay fever or nasal allergies)
Ondansetron (for nausea or vomiting)
Laxsol (for constipation)
Macrogol (for constipation)
13
Have any of your medications changed in the last 3 months?* This field is required.
Yes
No
14
Have you had any side effects from your medications recently?* This field is required.
Yes
No
15
Have you had any new or worsening symptoms recently?* This field is required.
Yes
No
16
Have you had a hospital visit or overnight stay related to your health in the last year?* This field is required.This doesn’t include hospital visits for injuries, planned surgery, or unrelated issues.
Yes
No
17
When was your last blood test?* This field is required.(if you have blood tests for these medications)
Within the last 3 months
3–6 months ago
6–12 months ago
Over 12 months ago
I’m not sure
I don’t have regular blood tests
18
When was your last appointment to review these medications?* This field is required.
Within the last 3 months
3–6 months ago
6–12 months ago
Over 12 months ago
I’m not sure
19
Which health condition/s do you take your regular medication for?* This field is required.Select all that apply
Type 2 diabetes
High blood pressure
High cholesterol
Gout
Asthma
Depression or anxiety
Using contraception
Chronic kidney disease
Other
20
Please tell us what condition this is: * This field is required.
21
Do you have chest pain at the moment or in the past few weeks?* This field is required.
Yes
No
22
Have you had worsening shortness of breath recently?* This field is required.
Yes
No
23
Have you had unexplained weight loss recently?* This field is required.
Yes
No
24
Have you been feeling unusually tired or fatigued recently?* This field is required.
Yes
No
25
Are you currently pregnant?* This field is required.
Yes
No
Not applicable
26
Are you planning to become pregnant in the near future?* This field is required.
Yes
No
Not applicable
Should be Empty: