Repeat Medication – ORDER FORM

IMPORTANT PATIENT INFORMATION

Please complete ONE form PER PERSON.

Make sure ALL details on the form (including contact number) relate to the PATIENT who the medication request is for, not who is submitting on their behalf.

If there is a problem with your request we may send you a text message to contact the surgery if you have consented to text messaging.

Requests for late-ordered medication are not considered urgent. It is the patient’s responsibility to ensure that repeat prescription requests are ordered on time. If you run out of important medication, please check with the pharmacy in the first instance, who may be able to provide you with an emergency supply.

To avoid complications with the ordering of your medication please ensure that your review has been completed if requested by the practice.

Ventolin Inhalers require a review with the Practice Nurse if you have run out of issues or it is no longer on your repeat therapy.

Only antibiotics on repeat prescription will be processed.

If you are requesting an item that was issued more than 6 months ago a review will be required unless the request is for seasonal medication.

Full name(Required)

Date of Birth(Required)

DD/MM/YY

Please list below medications required(Required)

I would like to collect my Prescription from(Required)

Do you consent to text messaging?(Required)

Court Road Surgery aims to utilise text messages for a number of purposes including, but not limited to: Notification of cancellation of appointments, booking appointments, test results, forms ready for collection, invitations to reviews or clinics. It will be the responsibility of patients to ensure that telephone contact numbers are kept up to date. By completing this form you are consenting to us contacting you by text.

If YES please add your mobile number(Required)

I agree to the Privacy Policy(Required)

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

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