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Prescription Request
Easily request repeat prescriptions at the click of a button - quick, convenient and hassle- free.
First Name
Last Name
Phone Number
Email Address
Doctors Name
Select Doctor
Dr. Sujit Sharma
Dr. Bharat Saluja
Dr. Abhijit Bidwai
Dr. Reetika Dhir
Dr. Abdulghani M Usman
Dr. Raj Dangi
Dr. Praveen Ravindranath
Dr. Antonio Da Costa
Dr. Nakul Parashar
Date of Birth
Last Consultation Date
Next Consultation Date
Medication Name & Dosage
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
Thank you
Thanks for reaching out. We will get back to you soon.
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Prescription Request Form