Script / Referral - only for renewal
Please note you can ONLY use this form if you have had a face to face consultation with one of our doctors in the past THREE months. Your regular GP will call you for a telehealth appointment as soon as they can. Could take up to a week. If you have not heard from Reception or from the Doctor please don't presume your request has been completed.

Please note Dr Galal Tadros and Dr Russell Bock will NOT be using this form - their patients must make an appointment (phone or face to face) for all script/referral requests. Any request for Dr Jessica Khouri will be forwarded to another Doctor while she is away on leave.

We will ignore this request if :
- You HAVEN'T had a face to face consult in the past 3 months
- You are asking for a NEW referral or prescription
- Any prescription for pain killers / drugs of addiction / sleeping tablets
Please make an appointment through our website to see your doctor face to face / telehealth.
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Regular GP *
Last Visit (must have been within the last 3 months) *
MM
/
DD
/
YYYY
Medication Name for REPEAT Prescription/Specialist Name for Referral
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