Prescription Mail Order Form

Prescription Mail Order Form

This form MUST be printed and posted with your valid Australian Prescription for ALL Prescription orders.
Ask us to pick it up and we will deliver medicines back the next day, if we file your prescription we can deliver it anytime in the future too

Please Print this page -
And Post it with your valid Australian Prescription to:

OnLine Pharmacy
847-849 Hay St
Perth 6000 WA

Queensland & Vic	Sydney	Western Australia	Country NSW
OnLine Pharmacy PO Box 889 Park Ridge 4125 Queensland	OnLine Pharmacy PO Box 2954 Taren Point 2229 NSW	OnLine Pharmacy 847-849 Hay St Perth 6000 WA

Your Details

Title:
Mr. Mrs. Ms. Dr.
Name:

Surname:

Your Home Address:

Post Code:

Phone:

Daytime Phone:

Email:

Delivery Details (if different than above)

Business Name:

Address:

Post Code:

Phone:

Fax:

Please Complete All Information Regarding Your Order

Please Write in Block Capitals.
Please give full details of each product ordered ie – brand name, size, flavour, colour, pack size, type of product (eg tablet, capsule, liquid, cream, ointment etc) Please give full details of only the prescriptions required to be dispensed below. IF YOU ARE SENDING PRESCRIPTIONS FOR MORE THAN ONE PERSON PLEASE FILL OUT AN ORDER FORM FOR EACH INDIVIDUAL PERSON.

If multiple items are listed on the prescription, include here only items required. (Please Print)

Name Of Product	Size	Qty	Price per product	Total Price









Sub Total				$
Delivery				$
Your Total Order				$

Please Choose Your Payment Method

Please charge my credit card:

MASTERCARD VISA BANKCARD AMEX DINNERS CLUB

Card Number:

Expiry Date:

Amex ID:

Signature:

Only signed orders can be accepted. Order will only be sent once funds have been cleared.

The Following details are only required
if you are ordering prescription medication.

Patient Details (if different than above)
(Only required if you are ordering prescription medication)

Name:

Date of birth:

Sex:M F
Health Care Card/Pension Card No:

Expiry Date:

Doctor Details
(Only required if you are ordering prescription medication)

Your Doctor's Name:

Address:

Postcode:

Doctor's PH:

Fax No:

Your Medicare Card Details (Only required if you are ordering prescription medication)
Card Number
Identifying Number
Expiry Date

Do you have any of the following drug allergies? (Only required if you are ordering prescription medication)
Please tick the appropriate box(es) below:
No drug allergies	Aspirin
Codeine	Erthromycin
Penicillin	Sulpha
Tetracycline
Other drug allergies

Do you have any of the following medical conditions? (Only required if you are ordering prescription medication)
No Chronic Conditions	Arthritis
Asthma	Diabetes
Epilepsy	Thyroid
Stomach Ulcers	High Blood Pressure
Glaucoma	Heart Condition
Other drug allergies
Other medical conditions

Prescribed Medicines
(Only required if you are ordering prescription medication)

Have you had this medication before

Not regularly taking any prescribed medicines - or -

Regularly taking medicine(s) that have been prescribed by a doctor or dentist.

The names of these medicines.

Non Prescription & Other Medicines
(Only required if you are ordering prescription medication)

Not regularly taking any non-prescription medicines - or -

Regularly taking medicine(s) obtained without prescription (Including from a pharmacy, supermarket, health food shop etc) eg. for headache, heartburn, etc. (including herbal and complementary medicines.)

The names of these medicines

Have you had this medicine before?
Yes No
Comments

Would you like us to substitute a less expensive equivalent medication for a brand name medication if available and if your doctor permits?
Yes No
Do you require a receipt for your private health fund?
Yes No
Would you like our Pharmacy to keep your repeat prescription?
Yes No

Privacy: We protect your information against unauthorized access or release. Your information is only accessible by the Pharmacy who processes your prescription. We will not give, sell, rent, or loan any identifiable personal information to any third party, unless you have authorized us to or we are legally required to do so.