Distance Supply Form
Date: …/…. /….
In order for us to provide a high level of care to you, it is important that we have accurate information about you, including administrative and personal details. We ask that you complete this form and return it to this pharmacy as soon as possible. We may be unable to provide some products or services without this information.
Patient details
| Name:
(exactly as it appears on your Medicare Card) |
Date of birth: |
| Address:
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Postcode: |
| Phone number (day): | Mobile number: |
| Medicare card number: | Expiry date: |
| Entitlement number:
(if applicable e.g. Pension Card, Health Care Concession card, Seniors Card, DVA Card) |
Expiry date: |
Please list your current medicines:
| Medicine Name | Active ingredient (if known) |
Strength and Dose Form | Dose instructions | Date last supplied |
| e.g. Panadol | paracetamol | 500mg tablets | 2 tablets FOUR times a day | 1 January 2012 |
Medical History
Please attached additional page if you need more room.
| Allergies:
(if no allergies, please write ‘no known allergies’)
|
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| Health conditions:
(e.g. blood pressure, visual impairment, confusion, asthma, diabetes, etc. )
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| Special needs:
|
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| Previous doctor: | Doctor’s address:
Doctor’s phone number: |
| Preferred delivery method:
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Note: Unless accurate information of your Medicare Number/s and Expiry Dates are provided, subsidised medicine under the Pharmaceutical Benefits Scheme will not be available.
