Myhealth Potts Point – Script renewal requests Step 1 of 3 0% Important Information Myhealth Potts Point is pleased to offer our patients the convenience of ordering your repeat prescription medication or a renewed referral to a specialist via our website. We'll need to ask you some questions about yourself, as well as the details of your request. You will need to be an existing patient of the clinic & to have been seen face to face by one of our doctors within the last 12 months to use this service. Scripts & referrals requested via our online ordering system may take between 1-5 working days to be returned to you. There is a charge associated with this service of $33.00 with an additional $2.00 postage fee. 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. Personal InformationFirst Name* Last Name* DOB*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*Patient's current body weight* Script/Referral Information Doctor*Select DoctorDr Amanda JohnsonDr Chad LimDr Misaki IkegameDr Neil BodsworthDr Victoria ShawDr Tara TranRequest type* Script renewal Referral renewal Service Fee* Price: Script details*For SCRIPTS please enter: 1. Name of medication & 2. Dosage. For REFERRALS please enter: 1. Name of Specialist; 2. Appointment date (if applicable) & 3. Reason for referral. Please check that all details are correct before submitting. Ensure all details are correct before submitting.Collection method* Collect at clinic ePrescription - script only (Medicare Card Holders) Fax & post direct to pharmacy Post to you Email to you (referrals only) If post to you is selected, the postal address the clinic has on file for the patient will be used. If you choose to have your script faxed directly to your pharmacist, they are required to obtain the original prescription so it will be posted to them.Please provide your preferred email or mobile number to receive your requested ePrescription* Fax Address: 02 9161 8029Mail Out Fee Price: Payment Information Billing Address* Street Address Address Line 2 Suburb State Post Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Payment Methods* Credit Card PayPal Credit Card* MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Total Cost $ 0.00 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 Myhealth Potts Point and that you have been seen face to face by one of our doctors within the last 12 months. Scripts & referrals requested via our online ordering system may take between 1-5 working days to be returned to you. There is a charge associated with this service of $33.00. 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
