Scripts and Reports - Ascot Vale Paediatrics

Please complete the form below to request a prescription outside of an appointment

General

Please allow at least 2 weeks' notice when requesting a prescription. Our paediatricians do not work every day, and advance notice helps ensure there is enough time for your request to be reviewed and processed.

Parents

Prescription requests are subject to approval by your doctor. Please ensure you have enough medication to cover the time required to process your request.

Prescription Request

Patient Name

Date of Birth

Parent/Guardian Name

Email Address

Confirm phone number for eScript

Medication Requested

Enter medication name	Enter medication strength	Enter quantity remaining

Date of Next Appointment (if known)

I agree to the $30 prescription request fee.

[The fee may vary depending on the request. You will be contacted if the fee is different.]

Need more information? Please Contact Us

Prescription Requests

Please complete the form below to request a prescription outside of an appointment

General

Parents