Online Prescriptions

Medical Background

Do you have a regular GP or clinic? *

Yes No

Name of GP or clinic (if known):

Are you currently pregnant or planning pregnancy? *

Yes No Not Applicable

Do you have any of the following conditions? (tick all that apply): *

Heart disease High blood pressure Diabetes Liver or kidney disease Mental health conditions None of the above

Do you have any known drug allergies? *

Yes No

If yes, list the medication names:

Have you had any adverse reactions to medications (not allergies)? *

Yes No

If yes, describe the reaction(s) and the medicine(s) involved:

Medication Continuation

Are you requesting a medication you have been prescribed before? *

Yes No

Are you still taking the medication as prescribed? *

Yes No

If not, explain why:

When did you last discuss this medication with a doctor? *

Within 6 months 6–12 months ago Over 12 months ago Don't remember

Have you experienced any side effects with this medication? *

Yes No

If yes, explain:

New or Changed Medications

Have you started any new medications in the last 6 months that your GP may not know about? *

Yes No

If yes, list names and doses:

Have you stopped or changed any existing medications recently? *

Yes No

If yes, explain:

Medication Prescription

This questionnaire has been created to streamline the process of preparing medical scripts during your consultation. The list below includes commonly prescribed medications, organised by name, brand, and dosage.

Please note:
Patients may indicate the medications they currently use or wish to discuss, but the presence of a medication on this list does not imply that all are available for automatic prescribing. Selections should be made thoughtfully and will be reviewed by the healthcare professional based on clinical need.

Blood Pressure

Perindopril - Coversyl - 2.5mg Perindopril - Coversyl - 5mg Perindopril - Coversyl - 10mg Ramipril - Tritace - 2.5mg Ramipril - Tritace - 5mg Ramipril - Tritace - 10mg Candesartan - Atacand - 4mg Candesartan - Atacand - 8mg Candesartan - Atacand - 16mg Candesartan - Atacand - 32mg Irbesartan - Avapro, Karvea - 75mg Irbesartan - Avapro, Karvea - 150mg Irbesartan - Avapro, Karvea - 300mg Amlodipine - Norvasc - 5mg Amlodipine - Norvasc - 10mg Bisoprolol - Bicor - 2.5mg Bisoprolol - Bicor - 5mg Bisoprolol - Bicor - 10mg Metoprolol - Betaloc, Minax - 50mg Metoprolol - Betaloc, Minax - 100mg Hydrochlorothiazide - Dithiazide - 12.5mg Hydrochlorothiazide - Dithiazide - 25mg Other

Cholesterol

Atorvastatin - Lipitor - 10mg Atorvastatin - Lipitor - 20mg Atorvastatin - Lipitor - 40mg Atorvastatin - Lipitor - 80mg Rosuvastatin - Crestor - 5mg Rosuvastatin - Crestor - 10mg Rosuvastatin - Crestor - 20mg Rosuvastatin - Crestor - 40mg Pravastatin - Pravachol - 10mg Pravastatin - Pravachol - 20mg Pravastatin - Pravachol - 40mg Other

Diabetes

Metformin - Diabex, Glucophage - 500mg Metformin - Diabex, Glucophage - 850mg Metformin - Diabex, Glucophage - 1000mg Sitagliptin - Januvia - 25mg Sitagliptin - Januvia - 50mg Sitagliptin - Januvia - 100mg Empagliflozin - Jardiance - 10mg Empagliflozin - Jardiance - 25mg Dulaglutide - Trulicity - 0.75mg Dulaglutide - Trulicity - 1.5mg weekly Semaglutide - Ozempic - 0.25mg Semaglutide - Ozempic - 0.5mg Semaglutide - Ozempic - 1mg weekly Other

Mental Health

Sertraline - Zoloft - 50mg Sertraline - Zoloft - 100mg Escitalopram - Lexapro - 10mg Escitalopram - Lexapro - 20mg Venlafaxine XR - Efexor XR - 37.5mg Venlafaxine XR - Efexor XR - 75mg Venlafaxine XR - Efexor XR - 150mg Mirtazapine - Avanza - 15mg Mirtazapine - Avanza - 30mg Duloxetine - Cymbalta - 30mg Duloxetine - Cymbalta - 60mg Other

Digestive Health

Esomeprazole - Nexium - 20mg Esomeprazole - Nexium - 40mg Pantoprazole - Somac - 20mg Pantoprazole - Somac - 40mg Omeprazole - Losec - 20mg Other

Asthma / COPD

Salbutamol - Ventolin, Asmol - 100mcg/puff Budesonide/Formoterol - Symbicort - 100/6 Budesonide/Formoterol - Symbicort - 200/6 Budesonide/Formoterol - Symbicort - 400/12 Fluticasone/Salmeterol - Seretide - 100/50 Fluticasone/Salmeterol - Seretide - 250/50 Other

Thyroid

Thyroxine - Eutroxsig, Oroxine - 50mcg Thyroxine - Eutroxsig, Oroxine - 100mcg Thyroxine - Eutroxsig, Oroxine - 150mcg Other

HRT

Estradiol - Climara, Estalis - 25mcg Estradiol - Climara, Estalis - 50mcg Estradiol - Climara, Estalis - 100mcg Tibolone - Livial - 2.5mg Other

Contraceptives

Ethinylestradiol/Levonorgestrel - Microgynon, Levlen - Standard 21-day tablets Desogestrel - Cerazette - 75mcg Medroxyprogesterone - Depo-Provera - 150mg IM every 12 weeks Etonogestrel - Implanon NXT - 68mg implant Other

Bone Health

Alendronate - Fosamax - 70mg weekly Risedronate - Actonel - 35mg weekly Calcium + Vitamin D - Caltrate, Ostelin - 600mg/1000IU Other

Allergy

Fexofenadine - Telfast - 120mg Fexofenadine - Telfast - 180mg Cetirizine - Zyrtec - 10mg Loratadine - Claratyne - 10mg Other

Nerve Pain

Pregabalin - Lyrica - 25mg Pregabalin - Lyrica - 75mg Pregabalin - Lyrica - 150mg Amitriptyline - Endep - 10mg Amitriptyline - Endep - 25mg Duloxetine - Cymbalta - 30mg Duloxetine - Cymbalta - 60mg Other

Prescription Policy

You may tick more than one box if it applies:

I have tried to book with my GP but could not get an appointment in time I am running low on my medication and have only a few days left Without this medication, I am at risk of becoming unwell Other

Please tell us briefly what brings you to see the doctor today. *

Medication cost acknowledgement *

I understand that the fee paid is for the consultation appointment only and does not include the cost of any medications. Any prescribed medications must be paid separately at the pharmacy.

Final Consent *

I understand my medications will be reviewed for possible interactions. The reviewing doctor may contact me if further information is needed. This is not a full medical consultation. I confirm all information provided is accurate to my knowledge.

Signature *

Confirm Your Details

We’ll use your email to match your booking. Please enter your Medicare number to confirm.

Email *

Medicare Number *

Medicare Reference *

Important: use the same email

We match your booking detais to this form using your email address. Please make sure the email below is exactly the same in the next form.

If the email doesn’t match, we may not be able to find your questionnaire automatically, which can delay your request.

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Request A Prescription

Medical Background

Do you have a regular GP or clinic? *

Name of GP or clinic (if known):

Are you currently pregnant or planning pregnancy? *

Do you have any of the following conditions? (tick all that apply): *

Do you have any known drug allergies? *

If yes, list the medication names:

Have you had any adverse reactions to medications (not allergies)? *

If yes, describe the reaction(s) and the medicine(s) involved:

Medication Continuation

Are you requesting a medication you have been prescribed before? *

Are you still taking the medication as prescribed? *

If not, explain why:

When did you last discuss this medication with a doctor? *

Have you experienced any side effects with this medication? *

If yes, explain:

New or Changed Medications

Have you started any new medications in the last 6 months that your GP may not know about? *

If yes, list names and doses:

Have you stopped or changed any existing medications recently? *

If yes, explain:

Medication Prescription

Blood Pressure

Cholesterol

Diabetes

Mental Health

Digestive Health

Asthma / COPD

Thyroid

HRT

Contraceptives

Bone Health

Allergy

Nerve Pain

Prescription Policy

You may tick more than one box if it applies:

Please tell us briefly what brings you to see the doctor today. *

Medication cost acknowledgement *

Final Consent *

Signature *

Confirm Your Details