Online Script Request

This form is for the use of current patients at Advantage HealthPoint who have already seen a doctor here.

All requests are reviewed by the doctor, and will only be filled if deemed appropriate (ie for long-term medications previously prescribed).

Paying the fee does not guarantee that the script will be filled, and no refund is applicable if not.

The $10 fee is payable by Paypal on completing this request

Please check one option:*

I agree to these conditions

I am not a registered patient of Advantage Healthpoint

Please register at clinic before using Online Script Request!

* denotes required field

Name:*

First

Last

Middle Initial:

Date of Birth:*

Phone:*

Your E-mail:*

E-mail confirmation:*

Who is your Doctor?:*

Dr Ari Kantzides

Dr Josh Hurn

How would you like to receive the script?:*

I will collect in person at clinic

Fax to other Pharmacy (pre-paid only). Enter name below

Name of other Pharmacy:

Items Required. Please copy accurately from previous script or medicine package:

Item 1:*

Dose (1) (mg):*

Item 2:

Dose (2) (mg):

Item 3:

Dose (3) (mg):

Item 4:

Dose (4) (mg):