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 You must call reception for an urgent same day prescription - the fee is $38 Service --Select a Service-- Collect from reception after 2 working days ($20) Faxed to your pharmacy after two working days ($25) Medication & Strength * Medication & Strength Medication & Strength Medication & Strength Medication & Strength Collection Method Fax to pharmacy Collect from reception Pharmacy Name and Address Pharmacy Fax Number