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REQUEST A REPEAT PRESCRIPTION
 
Please enter your details to request a repeat prescription.  Items marked () are mandatory.  

* Childs First Name
* Childs Family Name
* Date of Birth -  Day / Month / Year
/ /
Gender
MaleFemale
Apartment or Unit
* Street Number
* Street Name
* Suburb
* Postcode
* Salutation
* First Name
* Family Name
* email address
email address confirm
* Phone Number Preferred
Second phone number

Paediatrician

Ritalin Short-acting Tablets
Ritalin Short-acting Tablets
Ritalin Tabs 10mg Please select number per day
One Two Three Four Five Six Seven Eight Nine Ten Eleven Twelve 

Ritalin LA Capsules

Ritalin LA Capsules
Ritalin LA Capsules Strength
10 mg20 mg30 mg40 mg
Ritalin LA Capsules No per Day
One per dayTwo per day
             Ritalin LA Caps 2nd Strength
            2nd Strength 10 mg2nd Strength 20 mg2nd Strength 30 mg2nd Strength 40 mg
             Ritalin Caps 2nd No per Day
            One per dayTwo per day

Vyvanse Capsules

Vyvanse Capsules
Vyvanse Capsules Strength
30 mg50 mg70 mg
Vyvanse Capsules No per Day
One per dayTwo per day
            Vyvanse Caps 2nd Strength
           30 mg50 mg70 mg
            Vyvanse Caps 2nd No per day
           One per dayTwo per day

Concerta Tablets

Concerta Tablets
Concerta Strength
18 mg27 mg36 mg54 mg
Concerta No per Day
One per dayTwo per day
            Concerta 2nd Strength
           2nd Strength 18 mg2nd Strength 27 mg2nd Strength 36 mg2nd Strength 54 mg
            Concerta 2nd Strength No per Day
           One per dayTwo per day

Dexamphetamine Short-acting Tablets
Dexamphetamine Short-acting Tablets
Dexamphetamine Tabs No per Day
One Two Three Four Five Six Seven Eight Nine Ten Eleven Twelve 

Dexamphetamine Compounded Caps

Dexamphetamine Compounded Caps
Dexamphetamine Caps Strength
5 mg7.5 mg10 mg
Dexamphetamine Caps No per day
One per dayTwo per day

Strattera Capsules

Strattera Capsules
Strattera Capsules Strength
10 mg 18 mg25 mg40 mg60 mg80 mg
Strattera Capsules No per day
OneTwo
          Strattera Caps 2nd Strength
         18 mg27 mg36 mg54 mg72 mg
          Strattera Caps 2nd No per day
         OneTwo

Catapres (clonidine) Tablets

Catapres (clonidine) Tablets

Melatonin Prolonged-release Tablets

Melatonin Prolonged-release Tablets
Melatonin Tablets No per day
One per dayTwo per dayThree per day

Melatonin Compounded Capsule

Melatonin Compounded Capsule
Melatonin Comp Caps Strength
2 mg3 mg4 mg5 mg
Melatonin Comp Caps No per day
One per dayTwo per dayThree per day

Risperdal (Risperidone) Tabs

Risperdal (Risperidone) Tabs
Risperdal Tabs Strength
0.5 mg1 mg2 mg
Risperdal Tabs No per day
One per dayTwo per dayThree per dayFour per day
            Risperdal Tabs 2nd Strength
           0.5 mg1 mg2 mg
            Risperdal Tabs 2nd No per day
           One per dayTwo per dayThree per dayFour per day

Other Medication

Other Medication
Other Medication Name
Other Medication Strength
Other Medication No per day
Second Additional Medication (please specify)
Other Medication
Other Medication Name
Other Medication Strength
Other Medication No per day


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