Online Repeat Script Request

This service is provided for existing patients of Victorian Children’s Clinic. One of our General Paediatricians must have previously seen the child in the last 12 months at our clinic and a future appointment needs to be already booked. This service is to be used if there is an unexpected need for a prescription.

A prescription fee of $25 will be charged for this service. Payment is required at the time of the request. If your doctor feels that the request is not appropriate you will receive an SMS notification and the fee will be refunded.

By using this online script request form, you consent, if required, to a video consultation, to clarify any details of the clinical progress of your child.

Please allow 7 days for provision of script, in the event your paediatrician is on leave, the request may take longer and you will be notified by our reception team.

Online Repeat Script Request Form

Before we continue, please confirm your child has seen a paediatrician from this practice in the last 12 months.

Yes! My child has seen a paediatrician from this practice in the last 12 months.

Date of Birth

First Name

Last Name

Medicare Card Details

Medicare Reference Number

Medicare Card Number

Phone/Mobile

Paediatrician:

Medication Required:

Name of the Medication:

Dose:

Date current medication will run out (put today’s date if already run out):

How is child progressing?

Please provide a brief summary.

Child's Weight:

Child's Height:

Please choose Delivery Method

Please choose from one of the following:

Collect script from clinic ($20)

Send script in Post ($25)

Send to Pharmacy ($25)

Please enter your address below:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Pharmacy Name:

Pharmacy Address:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Fax Number:

Payment

A prescription fee will be charged for this service. Payment is required at the time of the request. If your doctor feels that the request is not appropriate you will receive an SMS notification and the fee will be refunded.