Repeat Prescription Support Service
GP Name
First Name
Last Name
Clinic Name
GP Practice
Clinic EDI
Healthlink EDI mailbox
Clinic 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 to?
New Zealand European
Māori
Samoan
Cook Island Māori
Tongan
Nuiean
Chinese
Indian
Other (such as Dutch, Japanese, Tokelauan): Please state below
If Other Ethnicity
NHI
Patient Email
example@example.com
Mobile Phone
-
Area Code (0x/02x)
Phone Number
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
Request Repeat Rx:
State your repeat prescriptions, one item per line
Supply period
10 Days
One Month
Three month
Preferred chemist/pharmacy
Which pharmacy this script will be sent to.
For GP2GP use EDI aratakwc
Medications
Allergies
Inbox
Classifications
Health Info
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
T&C agreement
By submitting this Request for Prescription , you agree to the Terms fo Service Agreement as published online.
Submit
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