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Online Repeat Prescription Request – Student Health Service - Manawatu Campus only

Patients of Student Health & Counselling Service - Manawatu may use this form to request repeat prescriptions for certain stable conditions. You will have to see your doctor for regular reviews and monitoring. Please allow up to 48 hours for your request to be processed. You will not be notified advising your script is available.

For urgent requests please call Student Health & Counselling Service directly on 350 5533.

All sections marked with (*) must be completed

If you are requesting a repeat of any antidepressant, antianxiety or antipsychotic medications, you will need to be seen by a Dr for each repeat prescription. Please Ph 06-350-5533 to arrange. Thank you.

First name:

Last name:

Date of Birth:

(dd / mm / yyyy)

Massey Student ID

(numeric only)

Phone (Include the area code and A DAYTIME number we can call you on if needed):

Mobile phone number:

Email address:

Your medication request:

Please enter only one medication per line

Medication 1

Medication 2

Medication 3

Any allergies?

Script Collection

Please tell us how you will collect your prescription (please note there may be a charge for
faxing it to your pharmacy):

I will pick it up from the medical centre
Please fax to my pharmacy as below

Pharmacy

Location

Fax number

Update or add your email address, cell phone, and home phone?

Yes, I consent
No thanks, not now

This will assist to keep your records update as we may need to contact you from time to time with important information about the practice or your health. We never sell, lend or distribute patient details to unrelated third parties except the Ministry of Health as agreed on your enrolment form. All use of your personal information complies with the Privacy Act.

Email Address

Page authorised by Campus Operations
Last updated on Wednesday 21 August 2019

Massey Contact Centre Mon - Fri 8:30am to 4:30pm 0800 MASSEY (+64 6 350 5701) TXT 5222 contact@massey.ac.nz Web chat Staff Alumni News Māori @ Massey