Prescription Medication Request Form

Please complete the questions on this form to help us provide the required medications or scripts.

IF YOU HAVE USED THIS FORM BEFORE AND WOULD LIKE TO ACCESS YOUR PREVIOUS INFORMATION LOGIN FIRST.

Note: Please allow at least 24 hours (weekdays) for standard repeat prescriptions to be processed. Patient history for all scheduled medications must be reviewed by a veterinarian – this is a legal requirement of the Veterinary Board of Victoria.

Medications and scripts are only provided if there is a clinical need by the patient and we have seen the patient in a period suitable for that patient and that condition. If we have not seen your pet for over 6 months a consultation may be required for us to prescribe or dispense more medications.

We cannot prescribe medications or write scripts for medical conditions not under our care – for example diabetes or thyroid medications. These health conditions need to be managed by veterinarians skilled in those disciplines. We are an ophthalmology only clinic and we only dispense repeat medications for eye conditions.

We will contact you once your pet's medications or prescription are ready to collect or have been sent by post.

There is a cost of $15 for a non-urgent script (this can contain more than one medication). An urgent script (less than 6 hours) will incur a cost of $25. A script prepared outside of normal business hours in incur a fee of $40. This fee applies whether the script is picked up at a clinic or posted.

The Pharmacy Guild of Australia have advised that pharmacists will no longer accept emailed scripts from veterinarians. We have been advised that only hard copy scripts will be accepted. You can pick these up from Animal Eye Care at East Malvern or we can snail mail them directly to your home.

Cold medications (Cidofovir and Interferon in Tears) will not be posted. It is no longer possible to guarantee that they will get to you in a timely manner and still cold even when sent with an ice pack. If needed you can pick these medications up from East Malvern or one of the other clinics that we visit.

Your Information

First Name(*)

Please let us know your name.

Your Email(*)

Please let us know your email address.

Last Name(*)

Please let us know your name.

Phone number(*)

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Postal Address(*)

Please provide your address

City(*)

Please enter your City/Suburb/Town

Post Code(*)

Please enter your post code

State(*)

Please select your state

Country(*)

Please enter your country

Pet Information

Pet's name(*)

Please enter the name of your pet.

Pet's Species(*)

Cat

Dog

Other

Please select your pet's species

if other

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Approximate Date of Your pet's last Veterinary Check up?(*)

Please select the approx date of your last vet check

Medication 1

Please note: We are unable to send digital scripts as they are not legally permitted from veterinarians, your script will be posted to the address provided in this form.

Please indicate what you require (*)

Written script

Refill medication

Please let us know if you need medication 1 as a prescription or actual dispensed medication.

Medication 1(*)

Please select the medication

If other:

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Frequency of use (eg. once daily)(*)

Please let us know how often you are giving medication 1 to your pet.

Which eye is affected?

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Medication 2

Please note: We are unable to send digital scripts as they are not legally permitted from veterinarians, your script will be posted to the address provided in this form.

Please indicate what you require

Written script

Refill medication

Please let us know if you need medication 2 as a prescription or actual dispensed medication.

Medication 2

Please select the medication

If other:

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Frequency of use (eg. once daily)

Please let us know how often you are giving medication 1 to your pet.

Which eye is affected?

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Do you have any concerns about your pet since your last visit or questions for the vet. If so please write them below

Please let us know your message.

Is there any other information that we need to know about?

Please let us know your message.

Delivery/ Pick up Information

Please select your preference(*)

I want to collect the medications/script from Animal Eye Care Malvern East.

I want to collect the medications/script from an outclinic that Animal Eye Care visits.

I would like the medications/script to be posted to me. (Please confirm address on the form)

Please select your collection/delivery preference

Cold medications (Cidofovir) cannot be posted.
Please select a pick up option instead.

Cold medications (Inteferon in Tears) cannot be posted.
Please select a pick up option instead.

Cold medications (Cidofovir) cannot be posted.
Please select a pick up option instead.

Cold medications (Inteferon in Tears) cannot be posted.
Please select a pick up option instead.

Select Clinic

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Please double check when we will next visit that clinic to make sure your pet has the medication when it is needed.

A veterinarian will review your request. If approved a nurse will contact you by phone to let you know when it will be ready and to take payment.

Charge for non urgent scripts (including postage of script) - $15
Charge for urgent scripts (less than 6 hours) - $25
Charge for scripts prepared out of normal hours - $40
Charge for actual medications (if supplied) – Please contact the clinic
Charge for medication postage - $19 (legally scheduled medications must be trackable when posting)

I understand and agree to the costs outlined above. You must select this box to continue

Would you like to save this information for future use?

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t. 03 9563 6488
181 Darling Road
Malvern East 3145 Victoria