Contact Us

Contact Form - Covid and Script Pharmacy (#6) (#11)

Do not use this form for urgent medical queries or emergencies , call instead.

Message Topic / Service Requested

Details of message topic

First Name

Last Name

Mobile number (preferred) else Telephone number

How do I want to collect the prescription

Collection from Reception

Send to Pharmacy (prepayment required) - provide details below

Pharmacy name, chain and location

How urgently do I need the prescription

Urgent/Within 24 hours - Enrolled= $40, Casual= $55, CSC card= $29

Within 2 to 3 working days - Enrolled= $30, Casual= $45, CSC card= $19

Fee payment and Terms & Conditions *

I will prepay the appropriate prescription fee within the next 24hrs to practice bank account (Westpac 03-0162-0098557-000) or via telephone payment, or Polipay instant online payment after submitting this form, to facilitate prescription handling.

Exceptions are : you are coming in to collect, patient is under 14yrs and enrolled, you have current Southern Cross full GP cover or your account is in sufficient credit.

I have read and agree to the Terms and Conditions

I acknowledge I need to have settled any outstanding accounts for any request to be processed, as per our T&Cs.

Date of Birth

Gender

NHI (if known)

Address

Details about myself - enrollment or memberships

I am a current Enrolled patient at HealthZone Medical

I am in the priority Group 2c (Medical/pharmacy frontline staff or Essential worker)

I am AUT Millennium staff (or associated business/organisation in the building

I am AUT Millennium member (pool, gym etc)

I am a family, household member or contact of the above (click all options above that apply)

I am enrolled/registered at another practice

I am not enrolled/registered at any practice

Enrolment interest

Yes, I am interested in enrolling with HealthZone Medical

No, I am fine for now, but thanks for asking

Reserve list (if we have spare vaccine towards end of a day we can call you in)

YES! put me on your reserve list also

Details of additional persons to be vaccinated - include name, date of birth, mobile, nhi (if known), address and email (if different) -one per line. Else enter None or N/A

Emergency Contact Details

Name

Relationship

Mobile Number

I confirm all the above details are correct

Yes

Any other information - optional

Your Message/More details here

Find us at....

AUT Millennium

Street Address

Postal Address

Electronic

Send a message/ Request a service/Vaccination

CONTACT DETAILS

Social / LISTINGS

HealthZone Medical