Halaxy - Patient Details

Patient Details

* Patient Details

* More Information

Prescription Fee Information How Your Prescription Request is Processed

* Payment Details * Prescription Request * Submit Request * Mark Completed

Patient

Before submitting your prescription request, we will ask you to do the following:

Enter your name and date of birth
Enter your card details (if not already completed)
Provide your prescription request details

Your request will be reviewed and either approved or declined. If approved, payment will be automatically taken. If your card details are not on file, you will need to add these details before we can schedule your prescription in Dr Law's diary.

Patient Details

* Name

Title

* First Name

Middle Name

Surname

Preferred Name

Pronouns

Gender

Date of Birth

Contact Email

Phone Numbers

Add New Phone

* Mandatory questions