Repeat Prescription Request Form

Before completing this form, please read this important information.

This form is only applicable for existing patients of Pitstop Health.

PLEASE NOTE: If you have not seen your treating Psychiatrist for more than 6 months, do not complete this form - You must contact us to organise an appointment for a medication review.

The approval of this request is at the Psychiatrist's discretion and may incur an "outside-of-consultation" script fee of $50.00
If your request incurs this fee, you will receive an e-payment link via sms. Once payment is made, your e-prescription will be sent via SMS
The minimum processing time is 5-7 business days
If you require an urgent prescription, please request this from your GP

Patient first name

Patient last name

Patient date of birth

Day

Month

Year

Phone Number

Medication 1

Medication 2

Medication 3

Medication 4

Important Notes