Prescriptions

Practice name
Enter your family name (surname):*
Enter your first name(s):*
Date of Birth*

DayMonthYear
You can enter your date of birth manually into the fields, or select the calendar icon to use the date-picker.
Select your gender:

MaleFemale
Enter your email address:
Are you happy for us to email you accounts information, such as invoices and statements?

YesNo
Are you happy for us to email you occasional practice alerts, such as flu jab alerts, events, and tips on healthy living?

YesNo
Enter your current address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enter your best contact number:*

Area CodePhone Number
Enter your chart number:
Who is your doctor?
Who is your doctor?
Medications:*
Please enter the name of the medication, strength and quantity. Put each medication on a new line. Please ensure you have your current medications in front of you for accuracy.
How would you like to pickup your script?*

Collect it from usPosted to youFaxed to a pharmacy
Due to the COVID-19 Threat Level 4 we are requiring that all scripts be faxed to a pharmacy. There is currently no additional fee for faxed or posted scripts
Pharmacy Name:*
Pharmacy Fax Number*

Area CodePhone Number
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your smoking status:*
The best thing you can do for your health is to stop smoking/not smoke
Would you like any help with quitting?*

YesNoN/A
What date did you stop smoking?*

MonthDayYear
When did you stop smoking?*
Would you like to be emailed a confirmation of your request?*

YesNo
Should be Empty: