Paediatric Script Request Form

Please complete and submit the below form.

Name Of The Patient

Date of Birth

Contact Number

Name of the Medication requested Name of the Medication requested

Dose of the medication required

How many repeats or number of medications left?

Date of last appointment

Date of Next Appointment

Other Information/ Details

For any STIMULANT MEDICATION repeat script the child must be seen by a face-to-face or through the Telehealth in the last 6 months.

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