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.