Action Plan | Melbourne Allergy Centre & Children’s Specialists (MACCS) Medical Group

For Patients
Health Professionals
- Our Specialists
- Referral Form
Resources
Contact
I Need A

1 1

Action Plan Request

Your action plan and script will be issued within 7 business days – if you require them earlier please contact us to ensure that this can be done.

A $30 fee is applicable. Please be advised we apply 1% surch (same as what you currently have written) Please note, If your child is not a patient of MACCS Medical Group we will not be able to issue you an action plan and/or script
Please complete the following details for your child's action plan.
01. Your child's details:
Patient First Name*
Patient Last Name*
Date of birth*
02. Your child's photos:

No photo uploaded
Patient Cropped Photo URL*
03. Family/Emergency contact:
First Name*
Last Name*
Work Phone
Home phone
Mobile phone*
Email*
04. Who is your child's allergy specialist?

Please select specialist

Dean Tey, Dr
Paediatric Allergist & Immunologist

Ee Lyn Su, Dr
Paediatric Allergist & Immunologist

Joanna Simmons, Dr
Paediatric Allergist & Immunologist

Jolene Fraser, Dr
Paediatrician with a Special Interest in Allergy

Mark Taranto, Dr
Paediatric Allergist & Immunologist

Marnie Robinson, Dr
Paediatric Allergist & Immunologist

Paxton Loke, Dr
Paediatric Allergist & Immunologist

Pei Ying Loo, Dr
Paediatrician with a Special Interest in Allergy

Sabeena Selvarajah, Dr
Paediatric Allergist & Immunologist

Sing-Jill Chow, Dr
Paediatrician with an Interest in Allergy

Tim Brettig, Dr
Paediatric Allergist and Immunologist
Who is your child's allergy specialist*
05. Do you require a:
Do you require an:*
06. Which food allergens does your child avoid?
Which food allergens does your child currently avoid?*
- Cow’s milk
- Egg
- Soy
- Wheat
- Sesame
- Fish
- Shell fish
- Peanut
- Tree nuts
- Other
Please select
Please Select
- All (Check this if it is more than 4)
- Almond
- Hazelnut
- Walnut
- Pecan
- Brazil nut
- Macadamia
- Pistachio
- Pine nuts
- Cashew
Other Food Allergens
07.What is your child's approximate weight?
What is your child's approximate weight?*
08. Which antihistamine does your child usually use?
Which antihistamine does your child usually use?*
Other*
09. Adrenaline autoinjector prescribed?
Adrenaline autoinjector prescribed?*
10. Does your child have asthma?
09. Does your child have asthma?
Does your child have asthma?*
- Yes
- No
10. Do they have asthma symptoms occuring 1x/week or more?
11. Do they have asthma symptoms occuring 1x/week or more?
Does your child have asthma symptoms occurring 1x/week or more?*
- Yes
- No
if Yes, we strongly recommend an asthma review by your GP or allergy specialist
10. Do you need an Epipen script?
11. Do you need an Epipen script?
11. Do you need an Epipen script?
12. Do you need an Epipen script?
Do you need an Epipen script?*
- Yes
- No
13. Comments
12. Comments
12. Comments
11. Comments
Comments

Script Request / Delivery Method
A $30 fee is applicable. Please be advised we apply 1% surcharge to all of our card transactions.
01. Please send my script to.
Please send my script to.
- My Chemist
  (Script will be faxed or posted)
02. Your Chemist Details
Chemist Name*
Chemist Address*
Address (Line 2)
Suburb*
State*
Postcode*
Fax*

Action Plan Request/Summary
Your child's details:

First Name

Last Name

Date of birth

Edit

Family/Emergency contact:

First Name

Last Name

Work Phone

Home phone

Mobile phone

Email

Who is your child's allergy specialist?

Do you require a:

Which food allergens does your child avoid?

What is your child's approximate weight?

Which antihistamine does your child usually use?

Does your child have asthma?

Do they have asthma symptoms occuring 1x/week or more?

Edit

Total

Item Action Plan Request $30

Item Epipen Script $10

Item Credit Card Surcharge $0.9

Total$30.9

Total$40.9

Payment Summary
Action Plan
Price: $ 30.00
Epipen Script
Price: $ 10.00
Credit Card Surcharge
Price: $ 0.90
Total Payable
$ 0.00
Credit Card*

Card Details

Cardholder Name
Name
This field is for validation purposes and should be left unchanged.

Getting to our practice

Our practice is situated directly next to the new Royal Children’s Hospital at 48 Flemington Road and is part of the Royal Children’s hospital precinct. MACCS Medical Group

Suite 1.1, Level 1
48 Flemington Road
Parkville Victoria 3052
View Google Map

Tel:03 9345 6888*
Fax:03 8374 3860*
Email:admin@maccsmedicalgroup.com.au

Travel Tips

Car Parking

Car parking is available at the Royal Children’s Hospital car park and also in surrounding streets- off street parking is available in Flemington Road and Gatehouse street but spots are metered (most 2 hours) and are limited.

Public Transport

There is a tram stop out the front of the 48 Flemington Road site. Trams 59 (from Elizabetth street) and 55 (from Williams street) stop almost immediately outside the practice.

Sitemap

For Patients
Health Professionals
- Our Specialists
- Referral Form
Resources
Contact

Action Plan Request

Script Request / Delivery Method

Action Plan Request/Summary

Your child's details:

Family/Emergency contact:

Total

Payment Summary

Upload & Crop Image