Patient Services - Dr Antoinette Miric

The forms below are for Existing Patients

Request for Script Form

Request for Script Form

Request for Script

Please complete this form if you are an existing patient and you would like to request a script.

Repeat scripts are issued at the doctor’s discretion, and not automatically issued on request.
No repeat scripts will be issued if the patient has not been seen in the previous seven-month period.
Please allow 3 working days to process repeat scripts. Scripts are not issued while Dr Miric is on leave. Please contact your GP.
Please note Dr Miric charges for repeat scripts.
Repeat Scripts need to be collected from the rooms and collection needs to be organized with Pulane.
If you are struggling financially please liaise directly with Dr Miric to ensure your treatment is continued.
No scripts are emailed to patients.

Patient First Name

Patient Last Name

Patient Email

Patient Date of Birth

Patient Contact Number

Medication being requested

Name of Medication	Dosage

I have seen Dr Miric in the last 7 months

Yes

I have an upcoming appointment in the next month

Yes

Script collections and emails

Please collect all repeat scripts. They will need to be signed for.
Please contact Pulane if you have not heard from the rooms, to confirm the script is ready for you – before you drive here.
Please note Neucon, Concerta, Ritalin, Contramyl and benzodiazepine scripts will not be emailed to the pharmacy or patient. They need to be collected and signed for.
If you have not been seen in the last 7 months, you will be asked to make an appointment and a one month script will be written.
Please organize payment for scripts with Pulane on collection, or before we email to a pharmacy.

I will collect this script

Yes

Pharmacy email address (Only some pharmacies accept emails from doctors rooms. Certain medicines cannot be emailed. Patients will not be cc’d on emails. Please put the correct email address here - not the branch name. Please note conditions above)