top of page

Private Prescription Request Form

Request

Personal details

Date of Birth
Day
Month
Year

Reason for request

Are you requesting a specific medication?
Yes
No

Note: Requests are reviewed individually. Listing a medication does not guarantee that a prescription will be issued.

Have you taken this medication before?
Yes
No

Relevant medical information

Do you have any medical conditions (past or current)?
No
Yes, please list below

Current medications & allergies

Are you currently taking any medications (prescribed, over-the-counter, or supplements)?
No
Yes, please list name and dose
Do you have any medications allergies or intolerances?
No
Yes

Preferred remote consultation time

Upload supporting documents

Upload any relevant documents 

Examples:

  • Previous prescriptions

  • clinic / GP / Specialist letters

  • discharge summaries

  • test results

Date
Day
Month
Year
bottom of page