Prescription Mail Order Form
This form MUST be printed and posted with your valid Australian Prescription for ALL Prescription orders.
Ask us to pick it up and we will deliver medicines back the next day, if we file your prescription we can deliver it anytime in the future too
Please Print this page -
And Post it with your valid Australian Prescription to:
 
Cross Roads Pharmacies

Head Office
100 Carlton Parade
Port Augusta
SA 5700


 
Your Details

Title:
Mr. Mrs. Ms. Dr.
Name:

Surname:

Your Home Address:


Post Code:

Phone:

Daytime Phone:

Email:

Delivery Details (if different than above)

Business Name:

Address:


Post Code:

Phone:

Fax:

Please Complete All Information Regarding Your Order
Please Write in Block Capitals.
Please give full details of each product ordered ie – brand name, size, flavour, colour,  pack size, type of product (eg tablet, capsule, liquid, cream, ointment etc)  Please give full details of only the prescriptions required to be dispensed below.  IF YOU ARE SENDING PRESCRIPTIONS FOR MORE THAN ONE PERSON PLEASE FILL OUT AN ORDER FORM FOR EACH INDIVIDUAL PERSON.

If multiple items are listed on the prescription, include here only items required. (Please Print)
Name Of Product Size Qty Price per product Total Price
Sub Total $
Delivery $
Your Total Order $
Please Choose Your Payment Method
Please charge my credit card:

MASTERCARD VISA BANKCARD AMEX DINNERS CLUB

Card Number:

Expiry Date:

Amex ID:

Signature:

  • Only signed orders can be accepted.  Order will only be sent once funds have been cleared.

The Following details are only required
if you are ordering prescription medication.

Patient Details (if different than above)
(Only required if you are ordering prescription medication)

Name:
Date of birth:

Sex:M F
Health Care Card/Pension Card No:

Expiry Date:

 
Doctor Details
(Only required if you are ordering prescription medication)

Your Doctor's Name:
Address:
Postcode:

Doctor's PH:

Fax No:

 
Your Medicare Card Details
(Only required if you are ordering prescription medication)
Card Number
Identifying Number
Expiry Date
Do you have any of the following drug allergies?
(Only required if you are ordering prescription medication)
Please tick the appropriate box(es) below:
No drug allergies Aspirin
Codeine Erthromycin
Penicillin Sulpha
Tetracycline  
Other drug allergies
Do you have any of the following medical conditions?
(Only required if you are ordering prescription medication)
No Chronic Conditions Arthritis
Asthma Diabetes
Epilepsy Thyroid
Stomach Ulcers High Blood Pressure
Glaucoma Heart Condition
Other drug allergies
Other medical conditions
 Prescribed Medicines
(Only required if you are ordering prescription medication)
Have you had this medication before
Not regularly taking any prescribed medicines - or -
Regularly taking medicine(s) that have been prescribed by a doctor or dentist.
The names of these medicines.
 
 Non Prescription & Other Medicines
(Only required if you are ordering prescription medication)
Not regularly taking any non-prescription medicines - or -
Regularly taking medicine(s) obtained without prescription (Including from a pharmacy, supermarket, health food shop etc) eg. for headache, heartburn, etc. (including herbal and complementary medicines.)
The names of these medicines
  • Have you had this medicine before?
    Yes No
    Comments
  • Would you like us to substitute a less expensive equivalent medication for a brand name medication if available and if your doctor permits?
    Yes No
  • Do you require a receipt for your private health fund?
    Yes No
  • Would you like our Pharmacy to keep your repeat prescription?
    Yes No

 

 

Privacy:  We protect your information against unauthorized access or release. Your information is only accessible by the Pharmacy who processes your prescription.  We will not give, sell, rent, or loan any identifiable personal information to any third party, unless you have authorized us to or we are legally required to do so.