Restricted Products Access Form

Please complete this form to allow us to assess the safety and suitability of the requested product at no additional charge. Please scan and email, or use our upload app, to send an image of prescription or referral note in support of your request. Please note that our practitioners will not always be able to make assessment on the provided information only and may request to see you in zoom or face to face consultation, pending Covid-19 lockdown conditions. 

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Please provide contact number if you prefer contact by phone.
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We need to know age to assess product safety.
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This information needed to assess safety and suitability.
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If exact name is no known, describe with own words.
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Health practitioners are registered doctors, naturopaths, pharmacists, homeopaths, and allied professions.
Please complete this field if a professional recommended this product for you.
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Your reply will assist Newtons practitioners to assess suitability
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Please specify.
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The fee for initial 1 hour is $120.