Contact 1 — Ashburton Health First

Repeat Prescription Form

Please fill out the form below.

If you don’t have email, you can drop off a medication list at reception.
Please allow 1-2 working days to complete.

Name

First Name

Last Name

Address

Pharmacy

Which Pharmacy would you like your prescription sent to? (select other and put under medications if sending to a different pharmacy)

Message

List your medications with dose and frequency. If you would your script faxed to a pharmacy, please name your pharmacy. Payment is expected before prescriptions are sent to the pharmacy