Prescription Request Form

Have you seen a doctor for your medication in the last 6 months NB: If No: Please request an appointment*
When Required*
Do you wish your prescription to be FAXED directly to your pharmacy?:(1)*
Name:*
Date of Birth:*
 / 
 / 
Address:*
Phone:*
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Mobile Phone:
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E-mail:
Please List which Medications need renewing:*
Do you wish your prescription to be FAXED directly to your pharmacy?:*
If Yes: Pharmacy Name
Details
I understand the following charges will apply:*
Prescription Charges:
Adult Scipt: $20.00
Child 0-5yrs Free
Child 6-12yrs $10.00
Child 13-17yrs $15.00
Additional Charges:
Same day Script: $5.00
Faxed Script: $5.00