Acute Medication Request Form

THIS FORM SHOULD NOT BE USED TO ORDER REPEAT MEDICATION

PLEASE COMPLETE THIS FORM IN FULL. MEDICATION WILL NOT BE PRESCRIBED IF YOU HAVE NOT DISCUSSED THIS TREATMENT WITH A HEALTHCARE PROFESSIONAL IN THE PAST 6 MONTHS.

REQUESTS FOR ANTIBIOTICS WILL NOT BE ACCPETED USING THIS FORM WITH THE EXCEPTION OF ‘RESCUE PACKS’ FOR PATIENTS PREVIOSULY ISSUED THEM FOR COPD/ASTHMA

Last Updated: 27/05/2022

Acute Medication Request Form

Full Name *

Address (Including Postcode) *

Date of Birth (DD/MM/YYYY) *

Contact Number *

Email Address *

Medication Request Information

What medication do you require? (Please ensure you name the medication required, the dose/strength and how often you take it) *

Please explain why you need this medication? (Please include as much detail) *

Nominated Pharmacy (Not available for collection at surgery) *

COLLECTION DETAILS - Your prescription request will be processed and will be sent to your Nominated Pharmacy. If you do not have a Nominated Pharmacy, we will allocate you a local Pharmacy. Please allow 5 working days from the time of your request to collection at your Nominated Pharmacy. You will be contacted if your request has been denied. If you have not nominated a pharmacy, YOU WILL NOT BE ABLE TO COLLECT THE PRESCRIPTION FROM THE SURGERY and your prescription will be sent to: Lloyds Tonyfelin Pharmacy

DISCLOSURE - This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. By completing this form, you I consent to the practice collecting and storing the data on this form.

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Acute Medication Request Form

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