Repeat Prescription Form

Please fill out the form below.

If you don’t have an email, you can drop off a medication list at reception.
Please allow 3-5 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).

Medications

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

How can I pay for my repeat prescription after I’ve requested it online?

When you send a repeat prescription to us, we will ask the Doctor to generate a prescription for your designated pharmacy. Once the generated script has been sent to the pharmacy for you to pick up we will e-mail you an invoice (like the one pictured).

You can come into our practice in person to pay at reception with this invoice. You can also use the bank number included in the invoice to pay online. We are located at 308 Havelock Street Ashburton.

When paying by direct credit, please use the name that is on the invoice and the invoice number that is highlighted in yellow as your reference. These numbers will be written in the same location on your invoice as the example image shows. This allows us to allocate the payment to your account accordingly.

Our online banking number is: 06-0837-0258556-00