MSS Request

Title *

First Name *

Last Name *

Date of Birth *

Mobile Number *

Email Address *

Home Address *

Suburb *

GP Name *

GP Address *

Chemist Name (optional)

Chemist Address (optional)

Date of next appointment (optional)

Form being requested *

Script - $30Pathology - $30Imaging - $30Form or letter - $30

Collection method *

Clinic pick upPostal delivery

What prescription do you need? *

What pathology do you need? *

What imaging do you need? *

What form or letter do you need? *

Postal address *Full address including suburb and postcode

TERMS AND CONDITIONS

1. Requesting a script, pathology and/or imaging will incur a fee to cover the cost associated with reviewing your medical records and issuing the form. 2. You must be an existing patient of My Specialists Sydney. 3. Scripts requests are: Only for re-issued scripts for patients seen in the last 3 months, Only for scripts prescribed by our specialists. For GP care and scripts, you will need to see your GP who is managing your health. Prescription and repeats will be at the discretion of our specialists dependent on your medical condition. 4. Pathology and/or imaging: You must notify us via phone or email where you completed the tests, Once completed, you must book an appointment to discuss your results. 5. If the above terms and conditions do not apply to your form request, please book an appointment to see one of our specialists. 6. The clinic has the right to decline a form request if not clinically appropriate. If declined, you will receive a full refund.

I agree to the above T&C’s and return correspondence via the above email address.

*

Signature *

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Date