Prescription Request Outside Appointment

Prescription Request Form

This form can be used to request a repeat prescription outside of an appointment. It may not be clinically appropriate for the prescription requested to be written. You will be advised by email if it is not appropriate. If it is appropriate, you will be sent an invoice and the prescription will be written on payment of the invoice. A screenshot of the payment will need to be sent to admin@sunshinep.com.au

Child's Name *

First

Last

Email *

Parent/Carer Phone Number (Mobile Preferred) *

Parent/Carer Name *

First

Last

Dropdown *

Medication Name *

Medication Strength *

Medication Dose *

Time(s) Of Day Given *

Chemist Postal Address & Fax Number (Extra $10)

Checkboxes

Cost of Collect = $15
Cost of Fax and Post = $25

Other Comments

Date Needed By *

Name

Sunshine Paediatrics

Sunshine is the love of Heaven poured out for all!

Prescription Request Outside Appointment