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Call Us: 03 9345 6888

Script Request

A $30 fee is applicable. Please be advised we apply 1% surcharge.
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.
Your script will be issued within 7 business days.
Most of our doctors are now able to do E-Scripts.
If you would prefer the original script to be posted to your home address or your local pharmacy, please make note of this in the comments section at the end of this form.
Please complete the following details for your child's script request.

IF YOU NEED AN ACTION PLAN AS WELL AS A SCRIPT, PLEASE GO TO THE ACTION PLAN REQUEST FORM INSTEAD. You will have the option to add an Epipen Script for an additional $10 at the end of this request section!

Please click the link to request a script if you see a General Paediatrician here at MACCS
01. Script required
Script required*
Other
02. Who is your regular specialist?

Please select specialist

Dr Bella Shadur
Paediatric Allergist & Immunologist

Dr Anneke Engwerda
Paediatrician

Dr Dean Tey
Paediatric Allergist & Immunologist

Dr Ee Lyn Su
Paediatric Allergist & Immunologist

Dr Gabby Mahoney
Paediatric Allergist & Immunologist

Dr Jolene Fraser
Paediatrician with a Special Interest in Allergy

Dr Mark Taranto
Paediatric Allergist & Immunologist

Dr Marnie Robinson
Paediatric Allergist & Immunologist

Dr Paxton Loke
Paediatric Allergist & Immunologist

Dr Pei Ying Loo
Paediatrician with a Special Interest in Allergy

Dr Sabeena Selvarajah
Paediatric Allergist & Immunologist

Dr Sing-Jill Chow
Paediatrician with an Interest in Allergy

Dr Sylvie Picker-Minh
General & Developmental Paediatrician

Dr Omega Leong
Paediatric Allergist & Immunologist

Dr Tim Brettig
Paediatric Allergist and Immunologist

Dr Yoko Asakawa
General & Developmental Paediatrician
Who is your regular specialist*
Steroid Ointment
A. Steroid Ointment Brand
Steroid Ointment Brand
Other
B. How many tubes used per month?
How many tubes used per month?
EpiPen/EpiPen Jnr
A. EpiPen strength required
EpiPen strength required*
*Please note that ASCIA expert opinion recommends updosing children to the adult EpiPen 300 mcg when their weight is >20kg (not 30kg as per manufacturer's recommendations)
- see https://www.allergy.org.au/hp/anaphylaxis/adrenaline-autoinjector-prescription
B. What is your child's approximate weight?
What is your child's approximate weight?*
C. Has your child had an EpiPen issued in the previous 6 months?
Has your child had an EpiPen issued in the previous 6 months?*
D. Does your child have asthma?
Does your child have asthma?*
- Yes
- No
E. Does your child have asthma symptoms occurring 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
Nasal steroid spray
A. Nasal steroid spray brand
Nasal steroid spray brand*
Asthma Preventer - Montelukast (Singulair)
A. Montelukast (Singulair) strength
Montelukast (Singulair) strength*
B. 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
Asthma Preventer - Flixotide
A. Flixotide strength
Flixotide strength*
B. Flixotide dose
Flixotide dose*
C. Flixotide frequency
Flixotide frequency*
D. Is your child using Flixotide with a spacer?
Is your child using Flixotide with a spacer?*
- Yes
- No
If Yes, we strongly recommend the use of a spacer, as this triples the amount of Flixotide delivered to the lungs.
E. Does your child have asthma symptoms occurring 1x/week or more?
Does your child have asthma symptoms occurring 1x/week or more?*
- Yes
- Uncertain
If Yes, we strongly recommend an asthma review by your GP or allergy specialist
We recommend a review with your GP/allergy specialist to determine the appropriate asthma preventer dose for your child
F. Would you like to contact your allergy specialist for an asthma review?
Would you like to contact your allergy specialist for an asthma review?*
- Yes, I would love to
- No, I will contact my GP to review my child's asthma.
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Section Break
03. Comments
Comments

Script Request / Patient Details

A $30 fee is applicable. Please be advised we apply 1% surcharge to all of our card transactions.
01. Patient Details
First Name*
Last Name (Surname)*
Date of Birth*
Gender*
02. Parent/Guardian Information (if applicable)
First Name
Last Name (Surname)
Relationship
Gender
03. Contact Details
Mobile*
Home (Optional)
Work (Optional)
Email*
04. Address
Address*
Address (Line 2)
Suburb*
State*
Postcode*

Script Request/Summary
Script

Script

Who is your regular allergy specialist?

Edit

Patient Details

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Gender

Parent/Gaurdian First Name

Parent/Gaurdian Last Name

Parent/Gaurdian Relationship

Parent/Gaurdian Gender

Contact Mobile

Contact Home

Contact Work

Email

Address

Suburb

State

Postcode

Edit

Script Delivery Method

Where would link your script to be sent to Your Chemist

Chemist Name

Chemist Address

Address (Line 2)

Suburd

State

Postcode

fax

Where would link your script to be sent to Your Chemist

Address

Address2

Suburd

State

Postcode

Edit

Total

Item Script$30

Item Credit Card Surcharge $0.9

Total $30.9

You receive 2 per year at a discounted rate, any more can be purchased at full price over the counter at a pharmacy.

Payment Summary
Script
Price:
Credit Card Surcharge
Price:
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
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Tel:03 9345 6888*
Fax:03 8374 3860*
Email:[email protected]

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.

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Script Request

Steroid Ointment

EpiPen/EpiPen Jnr

Nasal steroid spray

Asthma Preventer - Montelukast (Singulair)

Asthma Preventer - Flixotide

Section Break

Script Request / Patient Details

Script Request/Summary

Patient Details

Script Delivery Method

Total

Payment Summary

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