Repeat Prescription Request Form

Please use this form to request a repeat prescription from your psychiatrist

Please note, all questions with a * are required.

Please allow 3-5 days for the script to be sent to the pharmacy you have nominated.

Important things to check with your pharmacy before ordering a repeat prescription

Before ordering a repeat prescription please contact your pharmacy to:

Ensure you have no repeats remaining on the medication(s) you are requesting a repeat prescription for.

For stimulant medication:

Confirm the date that you are eligible to pick up your next prescription (you will need to provide this date when you email through your script request).
Ensure that the pharmacy has the medication you are requesting in stock.

First name

Last name

Phone

Treating Doctor Name

When do you need your prescription?

Pharmacy Name

What medications are you wanting a repeat of?

Please note that additional prescription fees will apply if additional medications are requested once this script request has been submitted.

For stimulant medication, when are you eligible to pick up your next prescription (i.e. has it been at least 21 days since you picked up your last script for stimulants)?

Please note, if it has not been at least 21 days since you last picked up a script for stimulant medication any script that is written will be ineligible. You will be charged for this script so please check that you are eligible for a script before submitting this form.

Please confirm the following:

My pharmacy stocks my medication (ring them first if unsure).

I confirm I have no repeats remaining.

All invoices to any clinician at Christchurch PsychMed are fully paid.

I have read and agreed to the Christchurch PsychMed terms of prescribing.

Any additional information?

REPEAT PRESCRIPTION REQUEST FORM

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