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Clinic Log In
Mail
Mail
NEW PATIENT FORM
Please be aware of your own personal security and do not email/add credit card or sensitive information within this form.
Select an option
Male
Female
Prefer not say
Are you pregnant?
Yes
No
Prefer no to say
Are you breast feeding?
Yes
No
Prefer not to say
Select an option
Pick up
Delivery
Choose an option
*If you chose delivery, please ensure you entered the correct address above.
Upload Script Pdf/Word
(Max 15MB)
Upload Script Pdf/Word
(Max 15MB)
Upload Script Pdf/Word
(Max 15MB)
Upload Script Pdf/Word
(Max 15MB)
OR
Upload Script IMAGE
(Max 15MB)
Upload Script IMAGE
(Max 15MB)
Upload Script IMAGE
(Max 15MB)
Upload Script IMAGE
(Max 15MB)
​​If you have more than four prescriptions to upload, please submit them all together in one email to
info@yscp.com.au
. ​
OR
I understand this is a New Patient Request and will recieve a Quote before my order is placed.
If this is a new medication, we strongly encourage you to contact us, as we do provide counselling
Send
Thank you for Your Request!
Are you ordering for a Medicine Shortage?
Yes
No
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