Repeat

Prescription Request

For Revital Health clients only, please use this form to order a repeat prescription of your products

Once we have received your completed form, our team will put together an invoice and send this to the email address specified.

After payment has been made, we will have your products prepared and ready for you at the earliest convenience!

*Please note, if your last appointment was over 3 months ago, we are unable to issue you with a repeat prescription. This is to ensure that we are maintaining the highest standards of practice for your ongoing treatment at Revital Health. To book a follow-up appointment and have your current treatment protocol evaluated, please head to our online booking portal, or give our admin team a call.

Name

First Name

Last Name

Phone Number

(###)

###

####

Which clinician do you see at Revital Health?

Please indicate what product/s you would like a repeat prescription for:

Multiple items can be selected.

Herbal (Liquid)

Compound (Powder)

Supplement

For clients requesting a HERBAL: If you are taking more than one prescribed herbal, please clarify which herbal/s you need:

For clients requesting a COMPOUND: If you are taking more than one prescribed compound, please clarify which compound/s you need:

For clients requesting a SUPPLEMENT: If you are taking more than one prescribed supplement, please clarify which supplement/s you need:

Please list any symptoms that have alleviated since beginning your prescription:

If you are taking more than one product and are finding it difficult to distinguish which alleviated symptoms can be contributed to which product, please indicate below how you are feeling overall.

Please list any new medications and/or supplements (other than products prescribed by Revital Health) that you have begun taking since your last appointment:

Please list any new symptoms that you have noticed and/or any new medical treatments that you have begun since your last appointment:

Please indicate whether you will be collecting your products from our clinic in Perth, or whether you would like your products posted to you:

*Postage fees apply

For clients requesting postage delivery, please provide your shipping address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional comments or concerns

Get In Touch

Follow Us

Explore

Address: 126C Hobart Street,
Mount Hawthorn, WA 6016

Phone: (+61) 449 597 431

Email: info@revitalhealth.com.au

We acknowledge that Revital Health is situated on the unceded lands of the Whadjuk Noongar people. We recognise their continuing connection to land, waters, and culture, and pay our respects to Noongar Elders past and present.

© Revital Health · Copyright 2025 · All Rights Reserved.