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Online Compound Medicine Order Form

Is the patient a child?*
- No
- Yes
First Name*
Last Name*
Name of contact person*
Relationship to child*
Full name of child or children if ordering for more than one*
Phone*
Email*
Are you aware of why you have been prescribed this compounded medication?*
- No
- Yes
This medication will be compounded specifically for you. It differs from a commercially available medicine which requires the manufacturer to meet the requirements of the Therapeutic Goods Administration (TGA) for addition of medicines to the Australian Register of Therapeutic goods
Are you ordering a Troche or Oral Suspension?*
- No
- Yes
Please select your preferred flavour*
- Peppermint
- Aniseed
- Tutti Frutti
- Chocolate
- Banana
- Orange
- Grape
- Raspberry
- Strawberry
- Coconut
- Spearmint
- Butterscotch
Are you currently taking any other prescribed medication?*
- No
- Yes
Please list the prescribed medication*
Are you currently taking any other over the counter medication, nutritional or herbal supplements, or supplements prescribed by a naturopath?*
- No
- Yes
Please list your over the counter medications below*
Please list your supplements below*
Are you pregnant or attempting to become pregnant?*
- No
- Yes
Do you suffer from any food or drug allergies?*
- No
- Yes
Please list any known allergies
Are you breast feeding?*
- No
- Yes
Do you have any current or past health conditions?*
- No
- Yes
Please select any that apply or specify other*
- Arthritis
- Asthma
- Chemical sensitivities
- Coeliac disease
- Diabetes
- Epilepsy
- Glaucoma
- Heart condition
- High blood pressure
- Inflammatory Bowel Disease
- Lactose intolerance
- Stomach ulcers
- Thyroid
- Other medical conditions
Please specify your medical conditions*
Do you or someone in your family have a history of any of the following*
- None
- Cancer
- Heart Disease
- Bleeding Disorders
- Osteoporosis
- Other
Please list other historical family medical conditions*
Do you have your prescription available to upload?*
- Yes
- No, the script is on file with Customised Compounding
Please upload a copy of your prescription*
Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 32 MB, Max. files: 5.

We are a compounding pharmacy which uses the state of art technology to prepare quality custom tailored medications.

CONTACT

Toll Free: 1300 725 868

info@customisedcompounding.com.au

OPENING HOURS

Our pharmacist is always available for consultation during business hours.

Monday – Friday: 9am – 5pm

Saturday - Sunday: Closed

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