Repeat Prescriptions

• Please use order form below
• Adults $25 / Under 18 $15 / Under 13 Free
• Fax / Post $5
• Allow 2 working days for your script to be ready.
• There is no need to confirm – we will contact you if needed
• You can pay online to 03 0802 0175929 00 – include your name and date of birth.
• Urgent Scripts or Last Consult over 12 months – Please book an appointment instead 

If you are human, leave this field blank.

First Name *

Surname *

Date of Birth *

(dd/mm/yyyy)

Phone Number *

Daytime contact number

Email *

Doctor *

Dr Mark Rogers

Dr Kim Lawson

Dr Victoria Flight

Dr Frances Matthews

Medications Required *

Please be as detailed as possible

Pick Up or Fax *

Pick up items at Cranford Pharmacy (On-Site at ProMed)

Pick up script at ProMed Reception

Or fax to pharmacy below ($5):

Pharmacy Name & Address

Submit