Medical Card Holder REPEAT PRESCRIPTION REQUEST FORM
Please note that this form is only to be used for routine repeat prescription requests.
This is not an appropriate format for acute or new medical issues.

Your prescription will be at your chosen pharmacy within 24 hours.
Name *
Medical Card Number *
Medical Card Expiry Date *
In format MM/YY
Address *
Date of Birth *
MM
/
DD
/
YYYY
Telephone Number *
Pharmacy *
Medication requested – please list by drug name *
Submit
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