Prescription Request Form

  • prescription

At The Hazelton Clinic it is clinic protocol that prescription requests are provided in writing, including electronically to:

  1. Ensure patient safety.
  2. Ensure that patients are aware of the medications they are requesting.
  3. Reduce the risk of prescribing unnecessary medications.
  4. Ensure accurate records of patients medication requests are retained.
  5. Minimise human error

Please complete the below form to process your prescription request:

    Full Name*


    Date of Birth*

    Pharmacy or GP to send prescription to*

    Medication Details: What Medication(s) do you need? Please include name of drug and dose - Number of pills per day/month.*

    Some medications require your latest stats: blood pressure, pulse, and weight. If you have your latest stats please upload them here:


    Please note: 

    • We can only issue repeat prescriptions for medication which was previously prescribed. For new medication, do not complete this form. Instead, contact the clinic at 021 493 6006 to book an appointment with your psychiatrist.
    • We strive to have prescription requests processed in 48-72 hours.
    • Once a prescription has been issued you will be notified via SMS. If further information is needed we will contact you at the phone number provided.