Long-term Prescriptions

LONGTERM PRESCRIPTION FORM
THIS FORM IS FOR LONG-TERM PRESCRIPTIONS, YOUR "REGULAR" PRESCRIPTIONS AND NOT FOR ONCE OFF OR SHORT TERM PRESCRIPTIONS, PLEASE DO NOT USE THE FORM FOR ANYTHING OTHER THAN LONG-TERM REPEAT PRESCRIPTIONS

Long-term repeat regular prescription request form

* Indicates required field

Name Address Phone number *

Date of Birth *

If you are filling this on behalf of patient please give your details *

When did you last have a consultation with one of our GPs *

Have you any drug allergies *

THIS FORM IS NOT FOR ACUTE SHORT TERM MEDICATIONS IT IS FOR REGULAR LONG TERM MEDICATIONS

This/These medication(s) are longterm medications that I am prescribed regularly *

Yes No

These are my regular LONGTERM medications prescribed by the GP surgery *

Yes No

PLEASE NOW LIST THE MEDICATION
TO REDUCE PRESCRIBING ERRORS LIST ALL THE TABLETS DO NOT WRITE "AS BEFORE" OR "LIST ON FILE"
WE NEED YOU TO LIST WHAT YOU ARE TAKING TO MAKE SURE IT MATCHES OUR LIST

NAME OF YOUR CHEMIST *

HAS THE PATIENT HAD ANY HOSPITAL ADMISSIONS OR OUTPATIENT VISITS IN WHICH MEDICATIONS MAY HAVE BEEN STOPPED OR DOSES CHANGED *

YES NO

List your medications and doses *

Please allow 72 hours for prescriptions to be ready and remember to take weekends and bank holidays into account.

Submit

Long-term repeat regular prescription request form

PLEASE NOW LIST THE MEDICATIONTO REDUCE PRESCRIBING ERRORS LIST ALL THE TABLETS DO NOT WRITE "AS BEFORE" OR "LIST ON FILE"WE NEED YOU TO LIST WHAT YOU ARE TAKING TO MAKE SURE IT MATCHES OUR LIST ​

PLEASE NOW LIST THE MEDICATION
TO REDUCE PRESCRIBING ERRORS LIST ALL THE TABLETS DO NOT WRITE "AS BEFORE" OR "LIST ON FILE"
WE NEED YOU TO LIST WHAT YOU ARE TAKING TO MAKE SURE IT MATCHES OUR LIST