Repeat Prescription Form - Christchurch Dermatologists, Dermatologic

Please use this form below to request a repeat prescription of medications prescribed by your doctor or dermatologist.

Please note that most medications require regular review for continued use. Your doctor or dermatologist may recommend an appointment prior to the prescription being issued if required.

Fields marked with an * are required.

Your name *

First name and Surname.

Your email *

Date of Birth *

Please enter in DD/MM/YYYY format.

Your Doctor *

Prescription items requested and quantities of each *

Delivery method *

Pharmacy name and street address *

Repeat scripts are available to patients who have been seen by one of our dermatologists in the last 6 months as long as there have not been any side effects from the mediation. Not all medications are available for repeat prescription without being seen by our dermatologist first.

I accept that a fee of $40 will usually apply *

KM Surgical & Dermatology Associates

Repeat Prescription Request Form

Fields marked with an * are required.