Doctor Request/Waitlist- Edmondson Park
Fill the form below to request a Doctor consultation, prescription, or other service.

**IF THIS AN EMERGENCY PLEASE PROCEED TO LOCAL EMERGENCY SERVICES**
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Participating Pharmacy *
Full Name *
Date of Birth  *
MM
/
DD
/
YYYY
Gender *
Required
Address *
Phone Number (as shown)
e.g. 0412345678
 *
E-mail (optional)
Medicare Number (optional)
(please include the 9-digit number, identifier number, and expiration date as shown)
e.g. 123456789-1   01/2030
This will be used to allow for faster e-script access
Purpose of Request
You may select any of the following to allow for faster processing
More Details (Optional)
You may wish to share more details on this form to aid with faster processing.
Privacy, Policies, and Disclaimer
https://drive.google.com/file/d/1V4Mc1lrhOrKdMYb158KspGGIlTVKuyGR/view?usp=drive_link

Patient Consent
We will only interpret and apply your consent for the primary purpose for which it was provided. Our staff will seek additional consent from you if the personal information collected may be used for any other purpose.
 *
PLEASE COMPLETE PAYMENT ONCE PAYMENT LINK IS RECEIVED
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