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Patient Prescription Request Form

Please fill out the form below to request a presciption from your doctor. You will be contacted when your script is ready for collection.

If the doctor requires a consultation before medication can be prescribed then we will contact you to make a booking. All types of requests incur a $40 fee prior of releasing a script to the patient or to a nominated pharmacy.

(Please fill out all the fields) (Form: scriptrequest)

Patient's Name

Doctor's Name

Medication and Dosage

Script Collection

Payment Details

I authorize BHC for Kids to use my credit card for the payment of $40 fee incurs for script request.
Credit Card Type
Card Number: