Millhouse Medical Centre Prescription Request Form

 Have you seen a doctor or visited the hospital recently?Yes No
 First Name:
Surname:
Address:
Phone:
Doctor Name:
 Do you wish the script to be sent direct to your pharmacy?Yes No
Cost is $20.00 per script, or $22.00 if faxed to pharmacy.  
Pharmacy Name:
Pharmacy Address/Fax:

This service is provided for our registered patients. 24 hours notice is required for repeat prescriptions; after this time prescription may be collected from MMC Reception, unless it has been faxed direct to chemist.  A nurse or doctor will phone if there are any problems with this request. Please Note that all patients requesting medication must be seen in person at LEAST once a year. 

 

Please list which medications need renewing:

Office Only:  □ tick when faxed Script also mailed

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