Comments

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

First Name*

Last Name*

Address (Please include suburb, state and postcode)*

Phone number*

Email address*

GP name*

GP clinic name*

Clinic or GP phone number*

Clinic or GP email address

Clinic or GP fax number

Any specific area of concern (tick all that apply). I…

• Take multiple medications (5 or more)
• Have a complex health condition
• Have recently been discharged from hospital
• Have experienced changes to my medication routine
• Have concerns about my medications
• Experience side effects from my medications
• Have difficulty managing my medications
• Have another reason (please specify):

Write a few words