Territory Medical Group – Script Renewal & Referral Requests

Script/Referral Information
Doctor*
Request type*
- Script renewal
- Referral
Script Renewal Fee
Price: $ 23.00
Referral Fee
Price: $ 23.00
Script/Referral details*
Enter the details of your requested prescription medication or referral request below.

Scripts – please include name and strength.
Referral - The name, specialty, address and reason for referral.

Please ensure all details are correct before submitting.
Collection method*
- Collect at clinic
- Fax direct to pharmacist
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: $ 1.50

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

MasterCard
Visa
Card Number 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 Territory Medical Group. Scripts and 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. This charge covers the time spent by our administrative staff & doctors to prepare your request. The clinic reserves the right to refuse any request they deem inappropriate. In such circumstances 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

Important Information