Online Prescriptions

We want to make things as easy and convenient for you as possible. Please fill out the form below to request a script. You will be sent a PDF on completion. Special Offer: While we set up the payment gateway all scripts will be free of charge! Note: This offer is entirely at the discretion of the doctor and may be cancelled at any time. BrowSearch-Feedonomy, the doctors involved take no responsibility whatsoever. This offer may be cancelled after you have completed the form due to the backlog, or any other reason whatsoever. BrowSearch-Feedonomy decision is final.

Patients Name:

Email Address:

Date of Birth:

Phone Number:

Physical Address:

Medical Aid Name/Number:

Person Responsible for Account:

The name and contact details of the pharmacy to send your prescription?

Emergency Contact:

Reason for Prescription:

Number of Medications Needed:

Who is your usual Doctor?

Name of Medical Aid: Medical Aid Number:

Medical History:

Allergies:

Additional Comments/Instructions:

By proceeding with this online prescription, you are agreeing to the following terms: 1. The charge for the issue of a repeat prescription is R150 and this amount will be charged prior to issuing the script. 2. That issuing of repeat prescriptions is at the doctor's discretion, and you will only be charged if the script is issued. 3. Prescription request may take up to 24 hours. (If a prescription is required urgently, please mark this on the form and we will let you know as soon as we can issue the script). 4. That medico-legally certain items cannot be scripted without a consultation eg. Antibiotics.