Request a prescription If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Patient's Name * Date of Birth * Contact Telephone * Address * Email Address * Your Usual Doctor * --Select a Doctor-- Dr Shelley Louw Dr Joseph Pearson Dr Joanna Thwaites Dr Karin Lamb Dr Sarah Fountain Dr Liz Schroder Service Two Business Days Faxed to Pharmacy ($24) Medication & Strength * Medication & Strength Medication & Strength Medication & Strength Medication & Strength Collection Method Fax to pharmacy Pharmacy Name and Address Pharmacy Fax Number