Acute (not on Repeat) Prescription Request Form

Please only use this form to request one-off medications that you have been prescribed before, or medication recommended by a hospital.

Before you submit your request

Your request will be subject to a doctor’s evaluation and/or review of hospital documentation.

You may require an appointment or telephone consultation before we are able to authorise and prescribe your request.

Full Name

Date Of Birth

Address

Telephone Number

Email Address

Drug Name

Drug Strength (e.g. 5mg)

Daily Dose (e.g. 1 tablet at night)

Reason for medication request

If you have been provided a 'Discharge Medication Summary' by the hospital, please upload the form using the file attachment button below