Order Form

Order Form

  • Distance Supply Form

    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.
  • Date Format: DD slash MM slash YYYY
  • Patient Details

  • Exactly as it appears on your Medicare Card
  • Date Format: DD slash MM slash YYYY
  • (if applicable eg. Pension Card, Health Care Concession Card, Seniors Card, DVA Card)
  • Current Medicines

  • Eg. Panadol, Paracetamol, 500mg tablets, 2 tablets 4 times a day, 1 January 2018
  • Medical History

  • (if no allergies please write "no known allergies")
  • (eg. Blood pressure, visual impairment, confusion, asthma, diabetes etc.)
  • Accepted file types: jpg, pdf.
  • 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.
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