E-follow up / Repeat e-script

First Name *

Last Name *

Date of Birth *

Residential address *

Postal address *

Mobile phone *

Email verification *

Send code

Submit code

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How can we help you? *

I would like to follow up after my initial e-consult I would like to discuss my treatment plan (eg. add/change of medication)I would like to request for repeat e-scripts (please provide names of your medications)

Please state your reason *

Pharmacy info *Please state pharmacy name, address, email and contact detail

Current medication name *

Average use per day (in millilitre or gram)

Frequency of use *

Everyday5 days/week< 5 days/week

When do you use it (can choose multiple) *

MorningMiddayAfternoonEvening

What were the effects of the medication? *

Any side effects? *

Do you require repeat e-script? *

YesNo

Overall symptoms scale *

1 (mild)2345 (moderate)678910 (severe)

How intense were your symptoms before starting treatment from 1 (mild) to 10 (severe)

1 (mild)2345 (moderate)678910 (severe)

How intense were your symptoms after starting treatment from 1 (mild) to 10 (severe)

1 (mild)2345 (moderate)678910 (severe)

Any questions/comments? *

Please indicate preferred time to receive a phone call from the doctor *

Weekday 9am - 12pmWeekday 1pm - 5pmWeekday 5pm - 6pmSaturday 9am - 12pmSaturday 1pm - 3pmOther

Preferred time/date for phone consult

The doctor will review your questionnaire and may give you a call to discuss your treatment plan.                                                                                                       Please send us an email to info@joyleaf.com.au if you do not receive any response within 1-2 business days.

Approval

YesNo

Treatment plan

Consultation fee

Amount

Please select one of the following *

Proceed with paymentRequest review by doctor

Please state reason *

Payment

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