Script Request

This form is only for patients already known to Dr. Christopher Sia privately.

This form should not be used for patient seen at the Alfred hospital or for new patients.

It should only be used for medications prescribed by Dr. Sia and you are going to run out of this medication before your next appointment with Dr. Sia.

See your local GP for prescriptions for other regular medications.

This for should not be used for scripts required urgently (within 48 hours)

If you use this service, a small fee of $20 may be added to your next consultation at the discretion of Dr. Sia.

Please note if details are not completely correct, a script may not be able to be generated.

First Name *

Last Name *

Date of Birth *

Home Address (Postal) *

Email Address *

Mobile Phone Number *

Medicare Number (including the IRN/Individual reference number) *This is required for e-script generation

Which Clinic do you see Dr. Sia at? *

TelecareParkside SpecialistsWattletree Medical Specialists

Preferred Script Delivery Method *

E-script (to patient mobile)E-script (to patient email)Post to pharmacyPost to patient home address

Pharmacy Name *

Pharmacy Email Address *If sending a script to a pharmacy, it will be sent as an escript to the pharmacy's email. You will need to get the pharmacist to check this email address to find your prescription after you have received notification from Dr Sia that the script has been sent.

What are the names of the scripts that you require? *Please specify the dose and frequency

Why do you need this script?

I agree that I am an exisiting private patient of Dr Sia. I have checked the information supplied above and verify it is correct. I agree to pay a small fee at next consultation with Dr Sia (at his discretion) for the use of this service. *

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