Requesting a script outside of your regular consultation

Please note: Script requests take 5 - 10 business days to action, depending on your practitioner’s availability.
This request will incur a $65 fee.
If you require the script urgently, please contact us to book an appointment with your practitioner, or alternatively contact your GP.
Your practitioner may request for you to book an appointment before providing you a script.

I agree that I have read and understand the above information provided to me. *

General Information

Have you had a consultation with a psychiatrist at Eton Place? *

YesNo

Script requests will only be processed for existing clients at Eton Place. Please close this form and contact us to book an initial appointment with one of our practitioners.

Practitioner Name *

When was your most recent review?If your most recent review was over 6 months from the request date, we will not be able to process this request. Please contact us to arrange a medication review with your psychiatrist.

Patient Information

Name *

Date of Birth *

Phone Number *

Email Address *

Prescription Information

Medication Name *

Dosage *

Frequency *

Medication Name

Dosage

Frequency

Medication Name

Dosage

Frequency

Collection or Postage of Prescription

Collecting your script

Your script will generally be sent as an E-Script to the primary contact phone number that we have recorded for the patient. If our doctors are unable to send an E-Script, we will sms you once your script is ready to be collected or sent to a nominated pharmacy. Please contact the clinic if the E-Script needs to be sent to an alternate phone number

Faxing and posting your script to your preferred Pharmacy

In line with Queensland Legislation:
- For any scripts that are faxed/emailed, a physical copy of the script must be received by the pharmacy within 24 hours.
- We are unable to fax/email prescriptions to patients directly
To ensure we meet this requirement, we must express post the prescription.
This may incur an additional $8.50 express postage fee, which must be settled prior to collection or fax/postage.

I confirm I have read and understood the above information. For my prescription: *

Please send E-Script to my mobile phone Please notify me when completed and I will collect from the practice. Please fax/email and post my prescription to my preferred Pharmacy.

Opting to have prescription faxed/posted

Pharmacy Name *

Pharmacy Address *

Street address *

City *

State *

Postcode *

Fax Number *

Email Address

Privacy Policy

Due to the Federal Privacy Act 1988, we require your written consent to collect personal information about you. Please read this information carefully and sign where indicated below.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat you. We may need to collect information from previous doctors, health care workers, pathology or x-ray services that you have consulted with, for the primary purpose of providing quality healthcare. This means that we will use the information you provide in the following ways:

Best assess your health care needs and provide medical treatment.
Administration purposes in running our practice. We may need to contact you using phone numbers provided by you. We may need to send documents, pathology and radiology referrals or letters to the email address provided by you.
Billing purposes and debt collection, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your care, including treating doctors, specialists and hospital booking staff outside this practice. This may occur through referral to other doctors, surgery at hospitals, for medical tests and in the reports or results returned to us following the referrals.
Collection of data for research purposes. This information is used to improve our treatment protocols, which will enable us to improve our quality of care. The data is kept in a secure manner and only staff involved in the research has access to them. You may be contacted at some time in the future for follow up purposes. No information that can be used to identify you will be included in any publication of the research results. You may withdraw from the research at any time.
You may be contacted for follow up in the future to ensure the long term results of your procedure.

You have the right to see any health information we hold about you as well as the ability to correct any details that are not accurate.

I voluntarily consent that I have read and agree all information provided to me. *

Full Name *

Signature *

Draw signature|Type signatureClear

Date *