Script Renewal Request As an existing patient please fill out all the required information to request your renewed prescription. Before proceeding to complete the details below please agree to the following disclaimer : Scripts are usually dispatched within 48 business hours from Total Health Care via Australia Post to your home address, or pick-up can be made available. Please be aware that this service attracts a fee of between $60.00 to $110.00 (non-Medicare) per script as a result of the administrative steps required. If script pick-up is selected, an email will be sent from Total Health Care Reception using the email address you supply below as to when your script is available to be picked up from Total Health Care, during business hours. Total Health Care will no longer be providing this service via pharmacies. If you require your script sooner and to avoid you not receiving your script when required, please plan to make an appointment with your relevant Practitioner at least one month prior to you requiring your script renewal. Please also be aware that a repeat prescription request does not guarantee that a script will be written for you. All requests are considered on an individual basis by your Total Health Care Practitioner and a decision is then made as to whether this repeat request is appropriate for your health care needs. A Total Health Care Receptionist will email you if your Total Health Care Practitioner requires you to make an appointment prior to the script being issued. There are some delivery risks in using this form and other electronic methods of communication, including electronic mail, with there being the risk of interception by third parties or non-receipt or delayed receipt of a message. Computer viruses, and similar damaging items, can also be transmitted through electronic means. Total Health Care uses virus scanning software to reduce these risks and ask that you do the same. However, it is not possible to completely eliminate the risk of introducing viruses by communicating electronically with Total Health Care. By ticking this box, you agree to all of the above terms and also release Total Health Care from all claims, losses, expenses and liabilities caused by any electronic risks encountered by you and arising directly or indirectly out of that communication. Please tick this box By ticking this box you agree to the payment of the applicable fee being made prior to the dispatch of your script. You confirm that all the information provided is true and correct, and you authorise Total Health Care to charge the card on file for the $60 - $110 required per script to be written outside of a consultation. Patient ID Number Please Select Your Practitioner Prof Michael KohnProf Simon ClarkeDr Jane HoDr Madhuri JainDr Chris Rikard-BellProf Garry WalterDr Philippa LevyDr Peter VauxDr Samantha HattleDr Ian ShermanDr Karen Proudman Guardian/Contact Name First Name Surname Date of Birth Email Phone Number Has a referral been submitted to Total Health Care in the last 12 months? YesNo Medicare Card Prescription Information Dosage of Prescription Diagnosed Previously Other Relevant Information Have You Already Booked Any Future Appointments yesno Delivery Options Home Delivery via Australia PostPick-up from Total Health Care during business hours (this option is only available outside of lockdown).Send Directly to Pharmacy Pharmacy Name (if applicable) Pharmacy Address (if applicable) Pharmacy Phone (if applicable) Please tick this box By ticking this box you confirm that all the information provided is true and correct, and you authorise Total Health Care to charge the card on file for the $60 - $110 that is required for a script to be written outside of a consultation Send
