Repeat Prescription Request Form

First Name *

Last Name *

DOB *

Mobile Number *

Reason for repeat *

Your Doctors Name *

Medication Requested *

Dosage

Number of times taken each day

Medication will run out by:

Medicare Card Number *

Position on Medicare Card *

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Note: Obtaining a script online will be up to the discretion of the treating psychiatrist and may take up to a week for a script to be issued. Scripts may incur a fee or in some cases, repeat prescriptions may require an appointment with your treating psychiatrist. As an alternative to this request form, you might be able to get a repeat prescription from your GP.

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