First Name
Last Name
Doctors Name Select DoctorDr. Sujit SharmaDr. Abhijit BidwaiDr. Reetika DhirDr. Abdulghani M UsmanDr. Praveen RavindranathDr. Antonio Da CostaDr. Nakul ParasharDr Bharat SalujaDr Raj Dangi
Date of Birth
Last Consultation Date
Next Consultation Date
Medication Name & Dosage
When are you running out of medication?
Any outstanding repeats left?
Any concerns or side effects with medication?
Payment Disclaimer I understand and authorise that there may be a fee involved in issuing a prescription, which will be confirmed by the doctor depending on the appointment type. I have read, understood, and agree to the information provided above. By clicking "I Agree", you acknowledge and accept these terms.
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Request Disclaimer Once the prescription request form is completed, your doctor will advise within 5 business days. All prescription requests are subject to clinician's discretion. For example - There is usually a need for clinical review prior to issuing any prescriptions including repeats for the purpose of safe prescribing. If patient requires a controlled medication and your current doctor is unavailable, please be aware that a consultation with another doctor is required in accordance with Medicare regulations and guidelines. Please click "I agree" below to agree and proceed with your prescription request. I have understood and agree with the above information provided.
I Agree Request Disclaimer
