Repeat Prescription or Referral

Please complete the following form to order repeat scripts or referrals. Repeats will only be issued if you have seen your doctor within the past 12 months. Please be aware that this will incur a $20 fee and can take up to 3 days. We will contact you in the event that there is an issue processing your request (some scripts may require a doctor’s visit). If you have not received a reply from reception within 2 business days please contact us on 9908 2233

Please note that a referral to a specialist cannot be back dated. Please make sure you have a current referral before your specialist visit.

If you require the script more urgently please contact reception on 9908 2233.

Fields marked with a * are required.

Patient Name*:

Date of Birth*:

Home Address*:

Contact Number*:


Prescription For -or- Referral To*:

Reason For Request*

I Want To*

If you would like it faxed, please supply fax number