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 Adam CampbellDr Rosie LaingDr Susan Gordon
Your request. Please enter only one medication per line
Script collection method (please choose one):
Pick up from Cashmere HealthPick up from Cashmere PharmacyFax to another Pharmacy
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.