Bassendean Family Practice

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39 Old Perth Road,
BASSENDEAN, WA, 6054

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08 9279 9422

Mon - Fri: 9am - 6pm

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Repeat Script Request
GP Recruitment 2024
Emergency

Home
Repeat Script Request
GP Recruitment 2024
Emergency

Home
Repeat Script Request
GP Recruitment 2024
Emergency

Repeat Script Requests Form

Home Repeat Script Requests Form

Online Repeat Script Requests

1

2

3

4

5

Are You an Existing Patient? *

Yes
No

Has your GP written a script for this medication for you before without a consult? *

Yes
No

Name *

First

Last

Email *

Contact Number *

Because drugs of dependence have special reporting requirements to be written I may need to book an appointment instead if it's been over a month since seeing my GP in person. Non-Consult Repeat Script Requests will NOT generally be made for narcotics, benzodiazepines and other sedatives. Examples include: • Panadeine Forte, Endone, Oxycodone, Targin, MS Contin • Diazepam/Valium, Oxazepam/Serepax, Temazepam, Stilnox. *

I understand

ONLY EXISTING PATIENTS CAN REQUEST A REPEAT SCRIPT

This is a REPEAT script request form ONLY - New Medications 1st need to be discussed with your GP at an appointment.

Date of Birth *

Street Address *

Suburb *

Postcode *

When do you Require your Script? *

Within 4 Doctor Business Hours ($35) - Collection ONLY
Within 4 Doctor Business Hours ($40.5) - POSTED
Within 24 Doctor Business Hours ($22) - Collection ONLY
Within 24 Doctor Business Hours ($27.5) - POSTED

Please Ask _________ to Complete my Script Request *

Dr Warren Saint
Dr Julian Charles
Dr John McAuliffe

Phone and Email When Script is Ready? *

Phone and Email Please
Email Only Please

How Many Different Medications do you Need on the Script? *

1
2
3

Dr John McAuliffe does not write scripts without an appointment - Please Call the Practice on 9279 9422 to book an appointment for your script or request an appointment via our website.

Pharmacy Details for POSTAGE

Pharmacy Name *

Pharmacy Phone *

Pharmacy Address *

Pharmacy Email *

First Medication

Medication Name (Correct Spelling Please) *

Dose/Strength (mg/mL/mcg) *

How often do you take this medication? (eg twice per day or once per week etc.) *

For what condition was this medication prescribed? *

Other instructions to your doctor (not required)

Second Medication

Medication Name (Correct Spelling Please) *

Dose/Strength (mg/mL/mcg) *

How often do you take this medication? (eg twice per day or once per week etc.) *

For what condition was this medication prescribed? *

Other instructions to your doctor (not required)

Third Medication

Medication Name (Correct Spelling Please) *

Dose/Strength (mg/mL/mcg) *

How often do you take this medication? (eg twice per day or once per week etc.) *

For what condition was this medication prescribed? *

Other instructions to your doctor (not required)

Payment Details

Stripe Credit Card *

Total

$ 0.00

We’ve formed a highly qualified team who know what they’re doing, but more importantly enjoy what they do.

Our Contacts

39 Old Perth Road,
BASSENDEAN, WA, 6054

Call Us 24/7
08 9279 9422

Mon - Fri: 9am - 6pm

Open Hours

Monday

9am - 6pm

Tuesday

9am - 6pm

Wednesday

9am - 6pm

Thursday

9am - 6pm

Friday

9am - 6pm

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