Radius Medical

Repeat prescription requests

	Patients of selected medical centres may use this form to request repeat prescriptions for certain stable conditions. You will have to see your doctor for regular reviews and monitoring. Please allow up to three working days for your request to be processed. The usual repeat prescription charges apply. All sections marked with () must be completed.* For urgent requests please call your medical centre directly. In an emergency dial 111. Please follow guidelines for input on the right of the screen. * = required field
First name (*)	Please enter your first name
Last name (*)	Please enter your last name
Birth date (*)	Please enter your birth date: DD/MM/YYYY	Please use this format: DD/MM/YYYY
Phone (*)	Invalid input - use numbers only, no gaps, eg 091234567	A DAYTIME number we can call you on.
Cell phone	Invalid input - use numbers only, no gaps	Please add your cellphone number if you have one.
Email (*)	Invalid Input
My Medical centre (*)	Davies CornerNew Lynn St Andrews Silverstream Ti Rakau Rototuna Whakatane Please select your medical centre.
My GP	Invalid Input

	Your request
Medication	Invalid Input
Any allergies? (*)	Invalid Input
	Tell us how you would like to be contacted when your script is ready:
Contact me by	Text messagePhoneEmail Invalid Input
	Please tell us how you will collect your prescription (please note there may be a charge for faxing it to your pharmacy):
Script collection	I will pick it up from the medical centrePlease send to me at homePlease fax to my pharmacy as below: Invalid Input
Pharmacy	Invalid Input
Location	Invalid Input
Fax number	Invalid Input