Prescription Request Form

Perscription Request Form

Please complete the form below to request a repeat prescription from Dr Thomas.

Once submitted, your request will be reviewed and processed within 2–5 business days. If the doctor determines a review is required before a prescription can be issued, our team will contact you to arrange a brief telehealth appointment.

Please ensure all details are correct, including medication name, dose, and pharmacy details.

PATIENT DETAILS

Full Name *

Date of Birth *

Medicare Number *

Phone Number *

Email Address *

MEDICATION DETAILS

Medication Name *

Dose *

Frequency *

Is this medication unchanged from your last appointment? *

YesNo

Select Script Option *

Repeat Prescription Only – $25 (private fee, not Medicare claimable)15-Minute Telehealth Review – Standard consultation fees apply

Please confirm the following: *

My symptoms are stableI am not experiencing new side effectsI am not experiencing suicidal thoughts or significant deteriorationI am not requesting an early repeatMy last appointment was within the past 6 months

If you answer “No” to any of the above (leave unticked), you may be required to book a telehealth review.

CONSENT

Consent & Acknowledgement *

I understand prescriptions are issued at the psychiatrist’s discretionI understand processing may take up to 3 business daysI consent to my information being reviewed by Dr [Name]

Patient / Nominee / Representative Signature *

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Name *

Date: *

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