Script Requests – ~ Geelong Paediatric Group ~

This service is to be used if there is an unexpected need for a prescription outside of appointments.

PLEASE READ ALL THE BELOW INFORMATION BEFORE SUBMITTING YOUR REQUEST, AS REFUNDS WILL NOT ALWAYS BE PROVIDED IF A SCRIPT IS NOT WRITTEN, FOR ANY REASON!!

Due to increasing administrative and medical demands, scripts between appointments will attract a $50.00 fee.

In most instances, your GP can provide scripts for your child’s medication. Especially if co-prescribing has been arranged.

If you require a prescription outside a booked appointment, please use this form at least 2 weeks prior to running out of medication, to allow us time to arrange the prescription to be written and processed. We however, can not guarantee the script will be available within the timeframe you may require.

Medications and scripts will only be issued if:
^{1. The patient has attended their appointments regularly as planned.
2. Has a future appointment booked
3. There is no change in dose / drug requested
4. The last repeat has been dispensed or expired, (legal requirement) and,
5. There is no outstanding accounts to be paid}

Please note:
* If a prescription is unable to be provided for any reason, a refund may not be given.
* Please ensure you have given at least two weeks notice for all requests and if applicable, began the co-prescribing process with your GP.

By using this service you consent, if required, to a video or phone consult, to clarify any details on the clinical progress of your child.
You also understand that you may only be supplied with enough medication or scripts to get you through until your next appointment.

Prescription Request Form

Patient details

First Name

Last Name

Date Of Birth

Person making the request

First Name

Last Name

Relationship To The Patient

Address

Suburb

State

Postcode

Country

Contact Mobile

Request Details

Your Usual Provider

Details of the request. (name of medication, dose, frequency taking, reason for the request)

Date medication will run out

If eScript is unavailable, which pharmacy would you like it sent to?

Date of the patients next appointment:

Payment

If the payment option does not appear, this means one or more **required fields (*)** have not been completed or contain errors. Please review all sections of the form and ensure all mandatory fields are completed correctly before proceeding.

Terms & Conditions – Script Request

I have read and agree to the above Terms and Conditions and understand that submission of a request does not guarantee approval, prescription, or fulfilment. All requests are subject to individual review, clinical assessment, and suitability, and may be declined at the discretion of the prescribing clinician or practice.

I understand that all script requests require clinical review and may not be suitable for processing without a current or recent consultation. Each request is assessed individually based on clinical appropriateness and safety.

I understand that fees associated with script requests are for the clinical and administrative review process and are generally non-refundable, including in circumstances where a prescription is not issued or the request is declined.

Payment Item

Pay with Card (Stripe) – Preferred