First Name (required)
Last Name (required)
Birthday.Please use this format: DD/MM/YYYY (required)
Phone number. A DAYTIME number we can call you on. (required)
Cell Phone. Please add your cellphone number if you have one.
Email (required). Please enter your email address.
Your Doctor (required)
Dr Kate DownerDr Vicki MartinDr Rebecca NichollsDr Donna HoldgateDr Andrew DickieDr Rosie LaingDr Susan Gordon
Your request. Please enter only one medication per line
Script collection method (please choose one):
Collect from Cashmere PharmacyFax to another PharmacyPick up from Cashmere Health
Name of the Pharmacy (Only complete if you want the script faxed)
We will ONLY contact you if an appointment with your doctor is needed, or if we require any further information to issue the prescription, otherwise you script will be available after 48 hours.