Request form — Repeat prescription

Privacy and confidentiality

We care about your privacy. We will follow the Privacy Act 2020 and the Health Information Privacy Code 2020 to protect your personal information. If you have any questions or concerns please contact us.

About you

First name*

Enter your first name or given name

Last name *

Enter your last name or family name

Date of birth (select day, month, year)*

Massey student ID number*

Enter your ID as a number

Which health centre do you use?*

Auckland Manawatū, Palmerston North

Select the campus health centre you are registered with. Wellington campus students need to request prescriptions through the ManageMyHealth website.

Contact details

Email*

Enter your email address in format: yourname@example.com

Daytime phone number*

Enter the number for the phone you use during the daytime

Mobile phone number

Enter your mobile phone number if different from your daytime phone

Your medication

How many different medications do you need prescribed? *

1 2 3

Medication 1*

Enter the name of one medication only

Medication 2

Enter the name of one medication only

Medication 3

Enter the name of one medication only

Do you have any allergies?

Yes (please specify) No

What allergies do you have?

How many days medication do you have left?*

Collecting your prescription

Your prescription will be emailed to your pharmacy. Please complete details below.

Pharmacy details

Pharmacy name*

What is your pharmacy's address?

Street address*

Enter your street address, like '128 Valley Road East'

Suburb*

City, town or locality*

Country*

Postal code or ZIP number*

Update your records

All use of your personal information complies with the Privacy Act 2020.

We never sell, lend or distribute patient details to unrelated third parties except the Ministry of Health as agreed on your health centre registration form.

Do you want to update your details on our system?

Yes, update my records with my correct email address and phone numbers No, do not update my records