ORDER YOUR PRESCRIPTION Please note this form is for reordering products from a previous consult only. If you want a review consultation please book here. THIS FORM IS BEING SUBMITTED BY A PRACTITIONER THIS FORM IS BEING SUBMITTED BY A PRACTITIONER Clinic Name(Required)Clinic Email(Required)Clinic Phone Number(Required)Person In Charge Of Payment(Required) Clinic (we will call clinic phone number above) Patient (we will call patient phone number below) Prescription Type(Required) New Prescription My Skin Pharmacy Refills External Pharmacy Refills Skin/Hair/Hormone Consult Product Refills Item(s) required, Previous Prescription Number (if known)Delivery OptionI want my prescription postedI will pickup my prescription from My Skin PharmacyYour Name(Required) Patient's First Name Patient's Last Name Your Phone(Required)Your Email Address(Required) Address Address Suburb State Postcode Upload Prescription File(For eScripts, please upload a screenshot of the QR Code or Barcode with the 18-digit alpha-numeric code) Drop files here or Select files Max. file size: 512 MB. Message: Mail Us Your Script To comply with Pharmacy Regulations, please supply the original copy of the script via post within 7 business days to My Skin Pharmacy – Shop 1, 530 Milton Road, Toowong QLD 4066. If your script is an eScript, we do not require the original copy to be posted. We will contact you as soon as we receive your script. Payment & Delivery Our staff will contact you by telephone to finalise payment. We use Australia Post Express. Please see the shipping price schedule for more information. Payment & Delivery Information Our staff will contact you by telephone to confirm your order, payment and shipping options. Shipping: Please see the shipping price schedule for more information. CAPTCHAPrivacy(Required) I agree with the storage and handling of my data by this website. - Privacy Policy *
