Medication Prescription Request
Child's details
First Name
*
Last Name
*
Preferred name (optional)
Date of birth
*
Medication requested
Medication name
*
Medication strength (e.g. mg or mcg)
*
Dosing regime (e.g. 1 tablet morning and midday)
*
Additional information
Do you have any concerns regarding medication side-effects/other relevant health issues for your child?
*
Yes
No
If yes, please provide details:
How much remaining medication do you currently have?
Are you happy to receive an escript to the default email on your child's record?
*
Yes
No
Please provide any additional information if needed:
Please be aware that this request is subject to your doctor's approval and that a review appointment may be required. A $45 fee will apply if this if this request is approved.
Sign and submit
Parent/guardian signature
*
Draw signature
|
Type signature
Clear
Parent/guardian name
*
Date
*
Please wait, files are uploading..
Submit
