The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Outpatient Pharmacy Medication Requests

Use this form to order medication refills for your prescriptions held at The Alfred Outpatients Pharmacy.

Just a reminder to please submit requests for medicines required over the Christmas/New Year period before FRIDAY 13TH DECEMBER to allow for possible delays with post over this busy period. If you need your medications urgently, please complete the form and contact Outpatient Pharmacy on gapharmground@alfred.org.au

Questions?

Please see the Frequently Asked Questions here if you have any questions.

Your Full Name

* must provide value

Your Date of Birth

* must provide value

D-M-Y

You Alfred Health Medical Record Number
"MRN" or "UR"

* must provide value

Mobile Phone Number

* must provide value

Do you have a Concession, Veterans Affairs or Medicare Safety Net number?

* must provide value

Yes

reset

Concession Card or Veterans Affairs Card Number

Safety Net Card Number
Please include SN or CN

How would you like to get your medications?

* must provide value

Collection

Delivery

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Medications need to be paid prior to delivery.

* must provide value

Send me an email with the invoice that has payment options

reset

You will receive an automated email with your invoice to this email address - please ensure it is correct.

You Email Address

* must provide value

Confirm Your Email Address

* must provide value

Email Addresses Don't Match

Please double check you have entered your email address correctly.

Medications can only be collected at The Alfred Hospital Monday to Friday between the hours of 8:30AM and 5:15PM
Please bring a credit or debit card with you to pay for your medications.
We require a minimum of 1 hour to process your request - during periods of high demand this may be longer.

Please note: if this order is placed outside of our usual business hours (refer to website for opening hours), the earliest collection time will be 11am the next business day

When would you like these medications to be ready for you to collect?

Date
Time

Is the collection date of ______ correct?

We're just checking - it's more than a month away.
You can continue if this date is correct.

Is the collection date of ______ correct?

We're just checking - it's more than two months away.
You can continue if this date is correct.

Delivery Information

You can find postage prices by visiting our commonly asked questions page.
We aim to have your medications dispensed and with Australia Post within 4 business days.

What type of delivery would you like?

* must provide value

Regular

Express

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Where would you like your medications delivered?

Street Address
Suburb/Town
State
Postcode

How many medications do you need refilling?
Please note: we need a copy of the prescription to be able to dispense your medication.
If you have run out of repeats, please speak to your prescribing doctor.
If you have the prescription with you, please email it to gapharmground@alfred.org.au

* must provide value

You can use any of the names you know for your medication.
Our Pharmacy team will review and dispense based on the prescription we have on file.

Please select how many medications you need refilling.

Medication Name	Medication Strength	Number of Refills	Is this dose the same as last time?

Medication Availability

We will do our best to dispense all of your requested medications.
There may be issues that mean we aren't able dispense all requests.
Please be reassured that a member of outpatients pharmacy team will contact you if there are any issues with your medication request.

For Office Use Only

Pharmacy Entry

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