Repeat Prescription Form

Repeat Prescription Form

Please complete the following form to order repeat scripts. Repeats will only be issued if you have seen your Specialist in the last 6 months.This will incur a fee of $30 (or $60 for certain medications including Psychostimulants) and take up to 3 business days to complete (plus the standard time for postage). Your credit or bank card details will be collected below.The script will be posted to the address provided below. We will call you to confirm that the script ison its way.
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
Date
Phone Number*

Area CodePhone Number
E-mail*
Repeat prescription requested (drug and dose)
Prescribing Doctor

My Products*

Simple Script$30.00AUD

Complex Script (Including Psychostimulants)$60.00AUD

Total $0.00AUD