Pharmacy Support Service
Queue Managed
Authorised Pharmacist/Technician Name
*
First Name
Last Name
Pharmacy Name
*
Legal name of pharmacy/chemist
Pharmacy/Chemist EDI
Healthlink EDI mailbox
Pharmacy Phone
-
Country Code
-
Area Code
Phone Number
Pharmacy Prescription Email Address
*
example@example.com
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Patient's Date of Birth
Gender
*
Please Select
Female
Male
Gender diverse
Unspecified
Which ethnicity Group does the patient belong?
New Zealand European
Māori
Samoan
Cook Island Māori
Tongan
Nuiean
Chinese
Indian
Other (Such as Duntch, Japanese, Tokelauan). Please state below:
If Other ethnicity
NHI
*
Patient Email
*
example@example.com
Phone Number
*
-
Area Code (0x/02x)
Phone Number
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
General Practitioner Name
*
Patient's enrolled GP
GP Clinic Name
*
GP Healthlink EDI
*
Find Healthcare Providers on Healthpoint
Request Repeat Rx:
*
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submitted electronically
Specified what channel
Submitted electronically
Toniq Extract
Latest Laboratory results review
*
Concerns raised
No concerns raised
Not checked
Blister pack required
Yes
No
N/A
Preferred chemist/pharmacy
*
Which pharmacy this script will be sent to.
Back
Next
Health Info
Over the last week, has the patient been feeling unwell that they needed to see a doctor?
*
Yes
No
Has the patient seen at their enrolled GP clinic?
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Approximate date if unknown exact (Within last 3 months, less than 6 months or greater?)
Latest BP
*
e.g. 120/70
Latest BP Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date of BP taken
Current weight
*
e.g. 70kg
Latest weight taken
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date of Weight taken
Previous Weight
e.g. 60kgs
Previous weight taken
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date of previous weight
Service fees (will be invoiced back to Pharmacy)
*
Initial request
No change request
Subsequent request with changes
Urgent Request? For same day/urgent requests we need to receive requests before 2 pm
*
Yes
No
Realignment of Medications
Yes
No
T&C agreement
By submitting this request for prescription, as the pharmacist , you can confirm that the patient health information is true and that you have confirmed that the patient has consented to share their health information as per the Terms for Services Agreement as published online (www.awc.net.nz). Medications with expired Special Authority will not be renewed.
Office use only
Assessment comments
Submit
Should be Empty: