Territory Medical Group – Script Renewal & Referral Requests Step 1 of 4 0% Prescreening Questions Are you requesting a prescription from your regular GP (“regular GP” = seen at least 3 times)?* Yes No Who is your regular GP? (If they are not on this list, you will have to make an appointment at our clinic)*Select your GPDr Rebecca GeorgeDr Geoff HarperDr Jenny DavisDr Lise LegaultDr Renato PenalozaDr Phil BrownscombeDr Sara MartinDr Bradley MartinDr Darren JewellDr Ibrahim BhattiDr Sandhli SharmaDr Lynn HeinDr Matt MiddletonDr Zara MansoorDr Danielle GreenYou are not eligible to use our script request service. Please make an appointment with a doctor first. Phone (08) 8948 4333Have you seen this GP in the last 3-4 months?* Yes No You are not eligible to use our script request service. Please make an appointment with a doctor first. Phone (08) 8948 4333Is this request for a Schedule 8 medication?* Yes No You are not eligible to use our script request service. Please make an appointment with a doctor first. Phone (08) 8948 4333 Important Information This service is only available to existing patients of the clinic and is at the discretion of the patient’s regular GP on a case by case basis. Patients must have had a consult with their regular GP in the last 3 to 6 months. Repeat medication prescriptions will only be for a maximum of 2 months duration and will not be provided for medication with addictive potential. Territory Medical Group is pleased to offer our patients the convenience of ordering your repeat prescription medication or a referral to a specialist via our website or clinic App. We'll need to ask you some questions about yourself, as well as the details of your request. 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 $23.00 for scripts and $23 for referrals. 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 Information First Name* Last Name* DOB* Day Month Year Email* Phone* Script/Referral Information Doctor*Select DoctorDr Rebecca GeorgeDr Geoff HarperDr Jenny DavisDr Lise LegaultDr Renato PenalozaDr Phil BrownscombeDr Sara MartinDr Bradley MartinDr Darren JewellDr Ibrahim BhattiDr Sandhli SharmaDr Lynn HeinDr Matt MiddletonDr Zara MansoorDr Danielle GreenRequest type* Script renewal Referral Script Renewal Fee Price: Referral Fee Price: 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 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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* MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 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 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
