Request Form

First Name *

Last Name *

Email Address *

Date of Birth *Press "enter" once date is chosen.

Please choose option required *

Contact Registration Form (Coming soon)Update Registration DetailsPrescription RequestDocument Request

Eligibility Questions

Have you attended an appointment in the last 6-7 months? *

YesNo - my appointment was cancelled by Dr KateNo

Great! You may be eligible. Please proceed to the next question.

Not Eligible for Prescription or Document Request

If you have not attended an appointment in the past 6-7 months, you will require an appointment for your prescription or document. Please do not proceed with submitting this form. Instead, please email admin@drkatelaw.com.au to arrange an appointment.

Did you cancel, reschedule or miss your most recent appointment? *

YesNo

Great! You may be eligible. Please proceed to the next question.

Not Eligible for Prescription or Document Request

Because you cancelled, rescheduled or missed your last appointment, you will require an appointment for your prescription or doument. Please do not proceed with submitting the form. Instead, request an appointment.

To request an appointment, please return to the top of this form and choose the option to request an appointment .

Are you requesting a prescription for stimulant medications (Vyvanse, Dexamfetamine, Ritalin/Methylphenidate, Concerta or Ritalin LA)? *

YesNo

You may be eligible to submit a prescription request. Please answer the below questions to check your eligibility futher.

Please proceed to the next section.

Are you currently happy with your stimulant medication dose/plan? *

Yes, it is going well and I do not need any changesNo, I want to make some changes

Great! You may be eligible. Please read the information below and then proceed to the next question.

Not Eligible for Stimulant Prescription Request

Because you would like to change your stimulant medication plan, an appointment is required. The stimulant prescription will be declined if you proceed with submitting this form. We can organise other prescriptions if required, or we can wait until your appointment.

If you are happy to continue the current plan for now and delay reviewing the dose/plan until your next appointment, please specify the issue below to help Dr Law decide whether to approve your script request.

Then, read the script fee information and proceed to the next question.

To request an appointment, please return to the top of this form and choose the option to request an appointment .

Please briefly explain why you are wanting to change your medication plan or dose. Long answers will not be processed; please try to keep the answer to 2-3 lines at most *

Prescription Fee: Stimulant Prescriptions

Stimulant prescription requests are not usually approved. Due to Dr Law's recent illness and limited availability, there is a temporary exception to this plan in certain circumstances to ensure there is no disadvantage to you.

Stimulant prescriptions take extra time to organise, as they are usually authority prescriptions (requiring an application process) and Dr Law will need to check your prescription & dispensing history via ScriptCheck WA.

The fee for a stimulant prescription is higher due to the additional time required. If you wish to proceed with your prescription request, you will be asked to confirm you are aware there is a higher fee.

This fee is currently $90 plus GST (total cost $99)

Please confirm you are aware there is a higher fee for stimulant prescriptions due to the extra time required *

I am aware of the higher fee for stimulant prescriptions ($99 including GST) and I would like to proceed with my prescription requestI do not wish to proceed

As you do not wish to proceed, please do not complete/submit this form. Please return to the top of this form and choose the option to request an appointment.

Prescriptions Required

Please enter the details of each prescription you would like to request. Please use a new section for each medication by clicking the box 'add another medication'.

Medication (name & strength): *

Current dose: *

When will your medication run out? *

Are you experiencing any side effects with your current medications? *

Yes - minorYes - majorNo

Please describe the side effects you are experiencing: *

Is your medication effectively managing your symptoms at the moment? *

Yes - I am happy with the effectNo - it is not effective, or not as effective as I had hoped. For now, I want to continue taking itNo - it is not effective, or not as effective as I had hoped. I want to change my medication plan as soon as possible

If your medication is not working well, please describe the reason for wanting to continue it (for now): *

When would you like your next appointment (approximately)? *

Comments (optional):

Submit Request

Please tick each box to confirm you are aware of the following: *

This request may take up to 7 days to be reviewed and either approved or declined (longer wait times are expected during periods of leave)A prescription fee applies to all prescriptions requested between appointmentsThe prescription fee must be paid before your scripts will be releasedThe prescription request will not be approved if you have cancelled your last appointment, have unpaid appointment fees, have not attended any appointments in the last 3-6 months, and/or at Dr Law's discretionStimulant prescriptions will not be issued without an appointment (some exceptions apply currently due to Dr Law's recent illness)

ScriptCheck WA

Dr Kate will check ScriptCheck WA for your medication dispensing history prior to prescribing any stimulants or other higher risk medications. Please refer to this website for more information:

ScriptCheckWA: Western Australia’s real-time prescription monitoring system (healthywa.wa.gov.au)

I confirm I am aware Dr Kate may check my prescription dispensing history via ScriptCheck WA before completing a script *

Document Request

Document/Report Fees

Brief documents (takes 5 minutes or less to complete):

First two documents per calendar year (requested or completed outside of appointment time):

No charge

Third and subsequent documents requested per calendar year (requested or completed outside of appointment time):

Charges apply: $30 + GST ($33 total) per document

Longer or more complex documents (takes more than 5 minutes to complete):

Charges apply: $60 + GST per 5 minute block (rounded to the nearest 5min). There is no charge for the first 5 mins

Document Fee Terms

Brief documents:

Your invoice will be issued after your document has been completed.
Your document will then be released following payment of your invoice

Long or complex documents:

A fee estimate can be provided on request before you decide whether to proceed with your request
We may request pre-payment of a portion of the document fee before work commences; you will be advised if this applies to you.

Please confirm you are aware there is a fee for documents requiring more than 5 minutes to complete *

I am aware of the document fee and I would like to proceed I do not wish to proceed

As you do not wish to proceed, please do not complete/submit this form. Please email admin@drkatelaw.com.au to request an appointment with Dr Law if you would like your document to be completed during an appointment.

Would you like a quote of the estimated fee before going ahead? *

YesNo

Document Details

Please enter the details of each document you would like to request

When do you need this document to be completed by? Please note, we require a minimum of 7 business days' notice. Last minute requests will not be actioned *

Please provide the details of the assignment you need an extension for *

Please describe the reason you require an extension. Be as specific as possible, including date of onset of symptoms, degree of impact on your functioning and what you have tried so far to manage this *

This type of medical certificate requires an appointment. If you would still like to request a certificate, you are welcome to do so, but it will likely be declined. If you wish to submit the request anyway, please outline the exceptional circumstances that currently apply *

Please provide the unit name, semester of enrolment, and reasons for withdrawing *

What was the census date for the unit you are withdrawing from? Your university website will have this information available. If you leave this blank, the time taken for Dr Law to look this up will be reflected in the document fee charged

Was your condition known & causing an impact on your ability to complete the unit requirements before the census date? *

Please describe the type of document you require, and who this should be addressed to *

Travel Advice

Overseas Travel

Before bringing medications overseas, it is wise to look up the laws of each country you will visit, and transit through, before proceeding. The Smart Traveller website is a good place to start, and you may need to contact the embassy for further advice.

Dr Law can provide a letter confirming your prescribed medications, but will not advise regarding the legal aspects of bringing medications oversease. it is your responsibility to research the legalities of brinigng your medication into each country.

Interstate Travel

You do not need a letter from Dr Law to bring your medication interstate. You can bring as much medication as you need for the duration of your trip. Some states will not dispense scripts from WA, but most will. If you need to collect a script while away, you can request for your pharmacy to release the script token to your mobile phone.

ADHD & Travel Information

Please click on the button below to open Dr Law's 'Travel & ADHD' information page (opens in a new tab):

Travel & ADHD Information

Which medications do you wish to bring with you? *

All of my prescribed medications Certain medications - specify below

Please list the medications you will be bringing overseas *

I am aware Dr Law strongly recommends I look up the law of each country I am visiting and transiting through before making the decision to bring my medications with me. I am aware I may face serious legal consequences for bringing medications into a country that prohibits these medications *

Who would you like Dr Kate to refer you to? *

What is their practice name? *

What is the reason for the referral? Please keep your answer brief, as the time taken to read your response forms part of the document writing time *

Document Details Required

Please provide as much information as possible to assist in completing the form, report or document.

If the document has questions about symptoms or functioning, answering these questions will reduce the time Dr Law spends on this document, and therefore reduces the fee charged. Dr Law will read your suggestions and consider these suggestions when completing the document, but will provide answers that are accurate and clinically appropriate. You don't need to use the correct terms, or give perfect answers, you are only being asked to give guidance.

Without sufficient information, Dr Law may request that you book an appointment to gather the information necessary to complete the document accurately.

Please give guidance regarding the questions or details required in the document. Please keep your answers brief (dot points please - no long paragraphs). Lengthy answers will take time to read and the time required will be added to your report fee.

Document Request - Please tick each box to confirm you are aware of the following: *

This request may take up to 7 days to be reviewed and either approved or declined (longer wait times are expected during periods of leave)Once approved, requests are actioned based on the order in which they are received. I will not be able to jump the queue. Long or complex documents will take time to complete. Dr Law will aim to provide an estimate of the turnaround time if my request is approved. I am aware I may need to pre-pay a portion of the document fee before work commencesI am aware the document will not be released until my invoice is paid (if a fee applies)

Please select the circumstances that apply to you: *

Middle Name *

Preferred Name *

Sex *

Gender Identity (Optional)

Preferred pronouns (optional)

She/her/hersHe/him/hisThey/them/theirs

Pronouns: comments (optional)

Occupation *

Relationship status

Contact Details

Patient - Mobile Phone *

Patient - Home Phone

Please note: appointment reminders will be sent via SMS and/or email. Other forms of correspondence may also be communicated via SMS and/or email.

Patient - Residential Address *

Patient - Postal AddressOnly complete if postal address is different to your residential address

Medicare Details

Medicare Number *

Individual Reference Number *

Expiry *

Who will be claiming the Medicare rebate? *

Patient Someone else

Please enter the claimant's details here:

The details of the claimant are required for the Medicare claim to be processed on your behalf. Once processed, the rebate will paid into the claimant's bank account by Medicare.

Name of Claimant *

Claimant Date of Birth *

Claimant Medicare Card Number *

Claimant Medicare Reference Number *

Emergency Contact Details

Please provide the details of your emergency contact. This person would not usually be contacted without your permission, unless it is an emergency.

Name *

Address *

Contact Number *

Email *

Consent

On very rare occasions, I am contacted by a person's family member, spouse, friend or other support person to discuss their condition or treatment. Although this doesn't happen very often, it is helpful to know what you would like me to do if someone contacts me.

The information we discuss can remain confidential unless you authorise information to be shared. There are some cirucmstances in which I cannot keep your information confidential, such as an emergency situation or if I reveuve a subpoena for your records.

If your next of kin, other family member or carer contacts Dr Law, do you consent to information being shared? *

YesNoI am unsure and would like to discuss this at my appointmentIt depends (please provide further information below)

Next of Kin More Information (Optional)

Healthcare Providers

Written Correspondence

Your referring general practitioner will receive a letter following your initial appointment outlining your history, symptoms, diagnosis and treatment plan. They will also receive regular updates regarding your condition and treatment. These letters are usually sent via secure messaging software. If your GP does not have this software, the letter will be sent by fax.

Correspondence will also be sent to your referring doctor regularly to ensure they remain informed of your treatment. You can also elect for your GP letters to be copied to your other healthcare providers below.

The following questions will ask for the details of your healthcare team. You do not need to include the referring doctor when answering these questions.

Is your usual GP different to your referring GP? *

YesNo

Please provide your usual GP’s details: *

Would you like regular updates to be sent to this GP? *

YesNoUnsure

Are you seeing a psychologist currently? *

YesNo

Please provide your psychologist’s details: *

Are you currently seeing any other healthcare providers not listed above, such as a medical specialist? *

YesNo

Please provide their name, role and practice details *

Additional Comments (optional):

Billing Information

Please confirm you are aware of the following information related to fees:

Consultations are not bulk billed & are not covered by private health insurance
Pre-payment of the estimated consultation fee must be received at least 2 business days prior to the consultation, via secure online payment or bank transfer
The total fee will be determined after the consult; extra time taken beyond the booked consultation duration will be charged as per the fee policy. Any additional fees will be invoiced following the consultation and are due the same day
Prescriptions, referrals, reports and other documents will not be released until payment is received
Admin fees apply for overdue fees as per the fee policy
Pre-payment may be required to book an appointment for those who have cancelled an appointment late or missed an appointment
If there is a need for treatments, such as medications, a procedure, and/or psychological treatments, there may be additional fees charged by the service provider. These fees are not set or charged by Dr Law and we recommend you enquire about costs with the service provider.
The fee policy and fee list can be accessed via the login protected area of Dr Law's website or upon request

Please review the fee policy and fee schedule documents (click button below to access):

Fee Policy

Fee Schedule effective 1st July 2023

Fee Schedule valid until 30th June 2024

I have read and understood the information about fees and billing *

Communication Policy

Please confirm you are aware of the following information related to fees:

Consultations are not bulk billed & are not covered by private health insurance
Pre-payment of the estimated consultation fee must be received at least 2 business days prior to the consultation, via secure online payment or bank transfer
The total fee will be determined after the consult; extra time taken beyond the booked consultation duration will be charged as per the fee policy. Any additional fees will be invoiced following the consultation and are due the same day
Prescriptions, referrals, reports and other documents will not be released until payment is received
Admin fees apply for overdue fees as per the fee policy
Pre-payment may be required to book an appointment for those who have cancelled an appointment late or missed an appointment
If there is a need for treatments, such as medications, a procedure, and/or psychological treatments, there may be

Our communication policy outlines how to contact us, which types of contact can be actioned, what to expect when communicating with us and our expectation that you will communicate respectfully with Dr Law and admin staff. The policy can be accessed here:

Communication Policy

I have read and understood the communication policy *

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