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REQUEST A REPEAT PRESCRIPTION
 
Please enter your details to request a repeat prescription.  Items marked () are mandatory.  

* Childs First Name
* Childs Family Name
* Date of Birth -  Day / Month / Year
/ /
* Gender
MaleFemale
Apartment or Unit
* Street Number

* Street Name
* Suburb
* Postcode

* Salutation
* First Name
* Family Name
* email address
* email address confirm
* Phone Number Preferred
Second phone number



Ritalin Short-acting Tablets
Ritalin Tablets 10 mg strength - please select number taken per day
One Two Three Four Five Six Seven Eight Nine Ten Eleven Twelve

Ritalin LA Capsules
Ritalin LA Capsules Strength
10 mg20 mg30 mg40 mg
Ritalin LA Capsules Number per Day
One per dayTwo per day
Ritalin LA Caps 2nd Strength (If more than one strength is required)
10 mg 20 mg 30 mg 40 mg
Ritalin Caps Second Strength Number per Day
One per dayTwo per day

Concerta Tablets
Concerta Strength
18 mg27 mg36 mg54 mg
Concerta Number per Day
One per dayTwo per day
Concerta 2nd Strength (If more than one strength is required)
18 mg 27 mg 36 mg 54 mg
Concerta 2nd Strength Number per Day
One per dayTwo per day

Dexamphetamine Short-acting Tablets
Dexamphetamine Tablets 5 mg strength - please select number per day
One Two Three Four Five Six Seven Eight Nine Ten Eleven Twelve 

Dexamphetamine Compounded Caps
Dexamphetamine Capsules Strength
5 mg7.5 mg10 mg
Dexamphetamine Capsules Number per day
One per dayTwo per day

Strattera Capsules
Strattera Capsules Strength
10 mg 18 mg 25 mg40 mg60 mg80 mg
Strattera Capsules Number per day
OneTwo
Strattera Caps 2nd Strength (If more than one strength is required)
10 mg18 mg25 mg40 mg60 mg 80 mg
Strattera Caps 2nd Number per day
OneTwo

Catapres (clonidine) Tablets (100 mcgs)

Melatonin Prolonged-release Tablets (Circadin 2 mg)
Melatonin Tablets Number per day
One per dayTwo per dayThree per day

Melatonin Compounded Capsules
Melatonin Compounded Capsules Strength
2 mg3 mg4 mg5 mg
Melatonin Compounded Capsules Number per day
One per dayTwo per dayThree per day

Risperdal (Risperidone) Tablets
Risperdal Tablets Strength
0.5 mg1 mg2 mg
Risperdal Tablets Number per day
One per dayTwo per dayThree per dayFour per day
Risperdal Tablets 2nd Strength (If more than one strength is required)
0.5 mg1 mg2 mg
Risperdal Tablets 2nd Number per day
One per dayTwo per dayThree per dayFour per day

Other Medication - Please specify below
Other Medication Name
Other Medication Strength please specify mgs.
Other Medication Number per day

Second additional medication - Please specify below
Second Other Medication Name
Second Other Medication Strength please specify mgs.
Second Other Medication Number per day




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