Prescription Request

This form allows you to order an online repeat prescription.

In many circumstances it is in your best interests for the doctor to be able to re-assess your condition in case medication changes are necessary. If an appointment with the doctor or nurse is necessary you will be contacted by telephone. Payment is required within 7 days and can be made by internet banking to 02-0820-0545719-02. An invoice will NOT be sent but we will text you when the prescription is on its way to the pharmacy. If you require an urgent prescription today please call the surgery on 03 3588266.

Your Full Name *

Your date of birth *

Your email *

Your phone number *

Your Usual Doctor

Dr Peter Sim

Dr Sharon Ashmore

Where will you pick up your prescription from? *

Kendal Pharmacy ($20)

Kendal Medical Centre ($20)

Faxed to your Pharmacy below ($26)

Name and fax number of your pharmacy

Your Required Medication Details *

Please state the name, the dose and how often you take it. eg. Paracetamol 500mg. 2 tablets four times a day. HINT : You can copy this information from the pharmacy label on your medication. Please put each drug on a new line.

Southern Cross Insurance

If you have Southern Cross health insurance which covers GP prescriptions we can charge the cost of your prescription directly to them at your request.

No thank you, I will pay for my prescription myself within the next 7 days.

Yes please charge my Southern Cross Insurance

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