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COMPLETE THIS ONLINE ENQUIRY Scripts 2U Discount Prescriptions for Australian residents

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Please complete this OnLine Enquiry Form and we shall respond by email with a price. Alternatively you can Print off the Form and fill in for mailing or faxing to us.

It is important all details are accurate, so we can respond with a price check on your prescription.  If you require assistance with your enquiry OR would prefer to talk to our pharmacists, we are available six days per week on 1300 587 345 - 8.30am-6.00pm [Mon-Fri] 9.00am-12.30pm [Sat] Eastern Standard Time.

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1. CONTACT DETAILS
Full Name *		Last Name *
Phone Number		Mobile Number
Email *
Home Address *		Delivery Address *
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2. MEDICARE & CONCESSION CARDS Please indicate what benefits you have
Type of Card	Card Number	Expiry Date on Card
Select Type of Card ... Medicare Card Pension Card Concession Card DVA Gold DVA White
Select Type of Card ... Medicare Card Pension Card Concession Card DVA Gold DVA White
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3.  MEDICATION DETAILS Please complete as accurately as possible your prescription details. Please choose your script type as indicated on your script (PBS-RPBS, PBS-RPBS Authority, Private, CTG)
Name of Drug	Strength	Quantity	Script Type
			Select Script Type ... PBS-RPBS PBS-RPBS Authority Private CTG
			Select Script Type ... PBS-RPBS PBS-RPBS Authority Private CTG
			Select Script Type ... PBS-RPBS PBS-RPBS Authority Private CTG
			Select Script Type ... PBS-RPBS PBS-RPBS Authority Private CTG
			Select Script Type ... PBS-RPBS PBS-RPBS Authority Private CTG
			Select Script Type ... PBS-RPBS PBS-RPBS Authority Private CTG
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4. FURTHER INFORMATION
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Conditions / Privacy Policy                   Discount prescription service in Australia

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