MyClinic Balaclava – Script Renewal & Referral Requests

Script/Referral Information
Doctor*
Request type*
- Script renewal
- Referral
Service Fee*
Price:
Script/Referral details*
Enter the details of your requested prescription medication or referral request below. Ensure all details are correct before submitting.
Collection method*
- Collect at clinic
- Mail out
- Fax direct to pharmacist
If mail out is selected, the mailing address on file at the clinic for the patient will be used.

If you choose to have your script faxed directly to your pharmacist, you will still be required to present the original prescription before you collect your medication.
Pharmacist's Fax Number*
Fax Direct to Pharmacist Fee
Price:
Mail Out Fee
Price:

Payment Information
Billing Address*
Street Address Address Line 2 Suburb State Post Code Country
Payment Methods*
- Credit Card
- PayPal
Credit Card*

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Total Cost
Terms and Conditions

By clicking submit, you are agreeing that the details you have entered are true, accurate and correct. You confirm that you are an existing patient of MyClinic Balaclava. Scripts & referrals requested via our online ordering system may take between 1-7 working days to be returned to you. If you require delivery in a shorter timeframe, please book an appointment with your regular doctor. There is a charge associated with this service of $38.00. This charge covers the time spent by our admin staff & doctors to prepare your request. The clinic reserves the right to refuse any request they may deem inappropriate to complete. In such a circumstance your fee will be reimbursed immediately and the clinic may contact you to follow up.

Please note if you have chosen to pay via PayPal you will be directed to the PayPal site to confirm payment after you click the 'accept' button below.
Acceptance of Terms & Conditions*
- Yes I accept

Personal Information