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
Medication Request Information
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