REPEAT PRESCRIPTION and RE-REFERRAL REQUEST APPLICATION.

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This is a service used on the following understanding 

1. The doctor has the right to not fulfil the request. ( in which case the applicant will be notified by return email)
2. Two full working days will be required between submission of the request and its collection.
3. Prescriptions and referrals are to be collected from St Agnes Surgery.
4. Only the doctors listed on the form will provide this service to their own patients.
5. It is practice policy that repeat scripts and re-referrals are issued without a consultation only by prior agreement.
6. Only the privacy of the email service used can be assured.
7. We accept no responsibility should the system fail.
8. The doctors listed, believe the email requesting concept to be innovative and likely to improve efficiency - we welcome your feedback.
9. A fee of $5 for a repeat prescription and $2 for a specialist re-referral applies.

ST AGNES SURGERY - EMAIL REQUEST FORM for
REPEAT  PRESCRIPTIONS  and REFERRALS.

   Your doctor at St Agnes Surgery is : 

    Your Name  ( Surname, Initials )  (Tab through fields)

    Address      

   

      * YOUR email ADDRESS :

   I request the following :

    REPEAT MEDICATIONS      

      Medication 1 

       Strength

      Medication 2

       Strength   

      Medication 3

       Strength

   SPECIALIST RE-REFERRAL

      Specialist's Name     

      Specialty             

    Script or referral is for :
    ( the patient, if not for yourself )

     Condition re-referral is required for :
                    

Click "submit" to email request            

  Click "reset" to clear the form and redo

Note : a FORM CONFIRMATION screen normally appears on your computer when SUBMIT has been successful - if a confirmation screen DOES NOT appear SUBMIT THE REQUEST again.

Web Privacy : No personal information is collected from persons accessing this web-site except where individuals submit a form request for a prescription - the information collected is that included on the form.
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