Manual Request - The Chislehurst Partnership

Non-urgent advice: Please note

Please allow a minimum of 2 working days for your prescription to be processed and be aware that it could take longer if your medication review date is overdue and/or there is a query relating to your request.

Repeat medications are reviewed at regular intervals, this helps us review your continuing need for the medication as well as enabling us to monitor the effects of medication by checking blood tests, blood pressure etc.

Patient Details

Patient Name

First Last

As it appears on your passport.

Postcode

The one used to register with your GP.

Patient Date of Birth

Your date of birth is required to verify your identity.

Sex of Patient

Male

Female

Other

As on your medical record.

Phone number to contact for this request

This phone number will be used for all correspondence relating to this request.

Medication Required

Do you require more than one medication?

Yes

Item Description

Strength

Quantity

Item Description Optional

Strength Optional

Quantity Optional

Item Description Optional

Strength Optional

Quantity Optional

Item Description Optional

Strength Optional

Quantity Optional

Item Description Optional

Strength Optional

Quantity Optional

Additional Comments Optional

Nominated Pharmacy

I have nominated a pharmacy and will arrange my collection from the pharmacy

I do not have a nominated pharmacy

I will collect from this pharmacy