Prescription Request

Request Type

To receive a repeat prescription you must have used our service previously.

*Out of pocket expense. Medicare rebates based on item# and HCP. 

Private - No Medicare Card: $49.99 - out of pocket.

Repeat prescription - Bulk Billed 

Private - No Medicare Card: $49.00 - out of pocket.

Patient Details

Patient Contact Details

Medicare

If you use Alias please write the Alias name & surname

The reference number is the number next to your name on your Medicare card.

Smoking History

You must be 18 years or over to purchase vaping products. We are unable to provide a prescription for Nicotine.

Health History

Consent

We are committed to protecting your privacy and know it is important for you to understand how your information is handled.

In submitting the information contained in this form, you:

Payment

Signature

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