Medication Script Request
Child's details
First Name
*
Last Name
*
Preferred name (optional)
Date of birth
*
Medication requested
Medication name
*
Medication strength e.g. in 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 email?
*
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 $30 fee will apply if this if this request is approved.
Sign and submit
Parent/guardian signature
*
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Parent/guardian name
*
Date
*
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