Form library · MED-004

Repeat prescription request

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Australian GP practices taking a repeat-prescription request from an existing patient. The practice may need a consultation before it prescribes. This form does not prescribe anything.

For existing patients of the practice. The person names the medicine and the pharmacy. The practice may need a consultation before it prescribes. It is a request for the practice to review. This form does not prescribe anything.

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Repeat prescription request

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional practice: Example Medical Practice, Subiaco. For existing patients of the practice. Example Medical Practice may need a consultation before it prescribes. This is a request. The practice decides whether to issue a prescription. This form does not prescribe anything.

Full name

Date of birth

DD/MM/YYYY

MobileMedicine nameHow you take itPharmacyAnything else (optional)I am an existing patient asking the practice to review this request. I understand Example Medical Practice may need a consultation before it prescribes, and that the practice decides whether to issue a prescription. This form does not prescribe anything.

Privacy: Example Medical Practice collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

I agree to Example Medical Practice collecting the health information on this form for my care.

Fields

Person
Name, date of birth and mobile.
Medicine
The name, in their own words. This example shows a made-up name.
How they take it
What is written on the last label, in their own words.
Pharmacy
Where they usually collect it.
Request
A tick for existing patients. The practice may need a consultation before it prescribes. This form does not prescribe anything.
Collection notice
A line the practice writes before anyone uses the form.
Health information
A tick. The practice collects the health information on the form for care.

Questions

Does sending this issue a prescription?

No. It only collects a request from an existing patient. The practice may need a consultation before it prescribes. The practice decides whether to issue a prescription. This form does not prescribe anything.

Can I name a real medicine here?

Use a made-up name on this example. Do not enter real patient details.