Slade Pharmacy Compounding Order Form

Compounded Prescription Order Form

To order your prescription, complete the order form below
IMPORTANT NOTICE

Please have a read of the Compounded Medication FAQs before you start ordering.
About your compounded medication
Welcome to the Slade Pharmacy online compounding order form. Compounded medications are custom made for each patient. As a guide the process takes around two business days to complete. 

We'll keep in touch with you via Email or SMS when it is ready to post or be picked up. 

**By law we require the original physical paper prescription before we can supply your medication.**

If you have any questions about your medication, please don't hesitate to call us on 03 8420 0700
Staff use only

Compounded Prescription Order Form

To order your prescription, complete the order form below
Staff member*
Add your name if filling out for a patient
Who is the prescription for?*

PrefixFirst NameLast Name
Address*
Email*
example@example.com
Mobile Number*
Please enter a valid phone number.
Date of birth*

DayMonthYear
Date
Gender*

FemaleMaleOther
Are you pregnant or breastfeeding?*

YesNo

Compounded Prescription Order Form
Have you used this medication before*

YesNo
Do you (or they) have any allergies, sensitivities or intolerances?*

YesNo
Please provide detail your allergies*
Name of drug, what happens when you take it?
Do you regularly take any other medications?*

YesNo
Please provide detail your current medications/supplements*

Email2SMS
example@example.com
Your Prescription

We will need the original prescription before we can release your medication
Address*

Street Address

Street Address Line 2

CityState

PostcodeCountry
Does the pharmacy have your original (ie paper) prescription?*

YesNo (select this to upload a copy of your prescription)
Would you like us to keep your repeats on file?*

YesNo
Upload a copy of your prescription

Cancelof
Take Photo of your Prescription

Delivery Details

Let us know if you would like pickup your script or have it mailed to you.
Delivery*

Australia PostPick up at Slade Pharmacy
Delivery Costs
- Express Post (room temp): $14.50
- Fridge items: $20.00

**Note: delivery timeframes may be variable with Australia Post**
Date of collection at site?*

DayMonthYear
Note: min 2 business days required to fill orders.
Date of dispatch?*

DayMonthYear
Note: min 2 business days required to fill orders. Note: due to storage conditions, no items can be sent by mail on Fridays. All items sent by Australia Express Post and will usually arrive within 24 hours.
Select your Slade Pharmacy pick up location*
Geelong/Frankston Orders takes an extra day to deliver and no orders are sent on Friday. Hence if you select Monday delivery, these orders will only be availalbe for collection on Tuesday. If you require your medication sooner please select another site for collection.
Werribee Orders are only available for pick-up on Tuesdays. If you select any other date other than Tuesday your order will be automatically pushed back to the following Tuesday. If you require your medication sooner please select another site for collection.

Prescription Payment

Select your drug to calculate the cost
Select your medication*
Select the item that matches your prescription (* denotes fridge items)
Atropine Eye Drops

Contains Benzalkonium Chloride 0.01% as a preservative. The eye drops has a 60 days expiry once made and 28 days in-use expiry once opened. Please pick up as soon as you are contacted to ensure you receive the maximum length of expiry.
Atropine Preservative Free Eye Drops:

Does not contain any preservatives, used for patients with sensitive eyes. Supplied in 4x 3mL bottles sufficient for ONE month supply. Each 3mL bottle has a 7 day in-use expiry once opened.
Slade Pharmacy ED Products:

Promix Regular, Promix Mega and Promix Ultra contain alprostadil, papaverine and phentolamine in different combinations in a 6mL multi-dose vial.

Prostin (all strength) contains alprostadil only in a 10mL multi-dose vial.

Slade Trimix Regular and Slade Trimix Extra contain atropine, papaverine and phentolamine in different combinations in a multi-dose vial.

All Slade Pharmacy ED products contain benzyl alcohol as a preservative. All vials have a minimum 28 day expiry at dispensing.

If you are unsure which product you need to order, please e-mail a copy of your prescription to orders.richmond@slade.net.au along with your contact details and one of our team will be able to help you decipher your prescription.
Do you need any of the following? (Select all that applies)

Urology Kit (containing 30 syringes + swabs) - $10.95Urology Kit with tablets (containing 30 syringes + swabs + 6x pseudo tabs) - $15.95Sharps Container 1.1L - $7.50
Please contact our compounding team
Currently, only the medications in the 'Select your medication' list are available to order online. Please email your prescription to compounding.orders@slade.net.au and one of our team will contact you within one business day.
Drug and Shipping Calculator (shipped)
Drug and Shipping Calculator (pickup)
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Total Due*
prevnext( X )
AUDPay securely using PayPal
Shipping
Drug Cost
Please press 'review order' to ensure all details are correct before you submit.

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Total cost
Additional notes
Should be Empty:

Compounded Prescription Order Form

IMPORTANT NOTICE

Compounded Prescription Order Form

Compounded Prescription Order Form

Your Prescription

Delivery Details

Prescription Payment

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