Prescription Order Prescription Order FormOrdering Prescriptions Online This online form allows you to order your prescription online by uploading a copy of your prescription or the QR code for your e-script and supplying us with your details. If you send us a copy of a script please post the original as soon as possible as we legally have to wait for it to arrive until your order is sent out. If you delay sending us the original script and thus your order sits with us longer than necessary it will reduce the expiry date of your product and we take no responsibility if this is the case.First Name *Last Name *Contact Phone Number *Email *Postal Street Address *Suburb *Postcode *State *Items to be Ordered *(Please separate multiple items with a comma and include required quantity)Script Type *New ScriptRepeat Script (on File)Prescription Upload *Please upload a copy of your script here then post the original prescription to us as per the important information outlined below.New or Existing Customer? *New CustomerExisting CustomerExisting Customer Please charge the card you have on fileCall me for payment detailsDelivery Options StarTrack Express CourierPick up from pharmacyDo you have any allergies/sensitivities? If yes, what are they? *Are you currently taking any medications? If yes, please list them. *Are you currently taking any supplements (vitamins/minerals/herbals)? If yes, please list them. *Do you have any current or past health conditions? If yes, please specify. *Please indicate the reason your taking this medication. *Women - Tick where applicable I'm pregnantI'm breastfeedingI'm on the pillNone of these applyDo you wish to talk to the pharmacist about your order? YesNoImportant information: In order to comply with The Poisons and Therapeutic Goods Regulations the pharmacy must receive the original prescription before we release the medications. Please send your original prescription to us as soon as possible. If there are any repeats on your prescription you may reorder your medication by phone, fax or email, or online. The number of repeats that you have will be printed on the label of your medication. Our postal address is: 1/130 Tamar St, Ballina, NSW, 2478 All orders must be accompanied by appropriate payment i.e. credit card (we will call you for details) or direct deposit. Please refer to conditions of sale under the shop menu. Refer to shipping for more information under the Shop Menu. VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
