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Digital Script Request
Complete the form below to request your digital prescription.
Important Notes:
This service is for one-time prescriptions of medications you are already taking
S4 or S8 medications or authority scripts cannot be provided
Ozempic, Mounjaro, or other weight loss medications are excluded
Approval typically within 2 hours
Patient Information
First Name
Last Name
Email Address
Phone Number
Date of Birth
Day
1
2
3
4
5
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7
8
9
10
11
12
13
14
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18
19
20
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24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Medicare Card Number
Pos
Expiry
Address
State
NSW
VIC
QLD
WA
SA
TAS
ACT
NT
Medical History
Hypertension
High Cholesterol
Congestive Heart Failure
Previous Heart Attack
Previous Stroke
COPD/Emphysema
Type 2 Diabetes
Osteoporosis
Chronic Kidney Disease
None
Medication Details
Medication Name
Strength/Dose
Quantity Needed
Current Prescriber
Date Last Prescribed
Reason for Request
Required Confirmations
I am currently taking this medication
I am unable to see my regular doctor in a reasonable time
I am not experiencing any side effects from this medication
If I experience any new symptoms, I will present to Emergency
I understand that no repeats are provided by this service
I understand that prescribing is at the doctor's discretion
Request Digital Prescription $19.95
