Prescription or Action Plan Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please use this form to request a new prescription from Dr Wainstein for your child's adrenaline autoinjector (EpiPen or Anapen) or a new ASCIA Action Plan (Anaphylaxis or Allergic Reactions). Please note: requests emailed directly to the doctor or The Children's Clinic will not be actioned.

Child's Name? *

Child's Date of Birth? *

YYYY

Can you confirm that your child has previously seen Dr Wainstein or another allergist at The Children's Clinic and has a booking for a follow up appointment at The Children's Clinic? *

Yes

If you require a new ASCIA Action Plan has the review date on your child's current ASCIA Action Plan passed? *

Yes

Not Applicable

If you require a new adrenaline autoinjector (EpiPen or Anapen) have your current devices passed their expiry date? *

Yes

Not Applicable

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms