Wellness on Wellington – Script Renewal & Referral Requests Step 1 of 3 0% Important Information Wellness on Wellington 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. You will need to be an existing patient of the clinic to use this service. 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 $18.00 for scripts and 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* DD slash MM slash YYYY Email* Phone* Script/Referral Information Doctor*Select DoctorDr David RingelblumDr Elise LiewDr Kim LeowDr Lona BrownDr Julia TrayerDr Kirrily EllertonDr Isaac BakerDr Danielle HumeDr Mihiri WeerasooriyaDr Kristina ConiglioDr Timothy TaiDr Kateena VogelDr Harishan TharmarajahDr Peter YeeDr Les SegalRequest 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* SMS script token 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 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 Wellness on Wellington. 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 I acknowledge that I have read and understand the FAQS before proceeding* Yes I accept
