Prescription Reorder

Prescription Request Form

For repeat prescriptions by established 4FR Health patients. Choose whether to collect the original signed script, have us email it to your pharmacy, or (for Schedule 0 to 4) email it to you. All requests are reviewed by the treating doctor and handled securely in line with POPIA.

First Name(s)

Surname

Email Address

Mobile Number

I consent to be contacted via WhatsApp

This Prescription is For

Prescription Fulfilment

Pharmacy Name

Pharmacy Location

Pharmacy Contact Info (Optional)

Which medication or prescription do you require?

Important Terms

For established patients requesting repeat prescriptions only.
Requests are subject to Chronic Medicine Management protocols and the treating doctor's discretion.
Schedule 6 prescriptions must be collected in person from our practice.
Schedule 6 scripts are never emailed to any pharmacy.
Prescription fulfilment may take up to 72 hours.
Prescription fee: R175.00 (Card/EFT) or R150.00 (Cash). This fee applies to the issued prescription document only, is payable upon collection, and excludes any medication costs.
Electronic prescriptions are only released once proof of payment has been received.
Subject to 4FR Health's Terms of Service and related Policies.

I confirm that the information provided is true and correct.