Are you an existing patient of CA Clinics
Yes
No
Only existing patients can request an additional script
First name
*
Last name
*
Email
*
Mobile
*
Medicare card no.
*
Individual reference no.
*
Valid to
*
Gender
*
required to validate Medicare card
Male
Female
Do you know what product you need a script for?
*
Yes
No
You can only request a script for a medicine that you have already been approved for
Would you like a script for a cheaper equivalent product if available?
*
Yes
No
Please send the prescription to:
CA Clinics preferred pharmacy - no additional fees
My pharmacy’s address - $27.50 in additional shipping and handling fees
My address - $27.50 in additional shipping and handling fees
Please provide any other comments or questions
Payment Information
Payment Amount
$19.00
inc. GST
Name on card
*
Card number
*
Expiry date
*
Security / CVC
*
Submit