Payment Details: (please tick one)

	Cheque
	Money Order
Visa   Mastercard   Bankcard   Diners Club   American Express
Credit Card Name: Credit Card Number: Credit Expiry (mm/yy): / Signature:

Medicare Information:
Medicare card name:
Medicare card no:
Medicare expiry (mm/yyyy):
Medicare sub number:

Healthcare concession no:
Healthcare expiry (dd/mm/yyyy):

Pension no:
Pension expiry (mm/yyyy):

Repatriation no:
Repatriation expiry (mm/yyyy):
Repatriation card type (please circle): Gold / Other

Safety Net no:

Change to generic brand? (please circle): Yes / No
Would you like us to retain your repeat prescriptions? (please circle): Yes / No

Allergies (Please circle)
Penicillin - Y / N
Tetracycline - Y / N
Sulpha - Y / N
Aspirin - Y / N
Codeine - Y / N
Erythromycin - Y / N
Other (Please specify) -

Medical Conditions (Please circle)
Glaucoma - Y / N
Diabetes - Y / N
Thyroid - Y / N
Epilepsy - Y / N
High blood pressure - Y / N
Arthritis - Y / N
Heart Condition - Y / N
Stomach Ulcers - Y / N
Asthma - Y / N
Other (Please specify) -