Acute Prescriptions Request Form

Last Updated: 09/12/2021

Please note, this form should be used for requesting acute medication only. Any requests received for repeat prescriptions will be rejected with no action being taken. Please allow three full working days (72 hours) for acute prescriptions to be processed. Remember to take weekends and bank holidays into account.

Your Details

First Name *

Surname *

Date of Birth *

Phone Number *

Email Address *

Medication Required

Item - eg Atenolol? *

Strength 1 - eg 50mg

Quantity - eg 28 tabs *

Additional info e.g. extra medication needed as going away *

Collection Details *

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

I wish to collect from the Practice

Preferred Pharmacy

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. *

I consent to the practice collecting and storing my data from this form.

Acute Prescriptions Request Form

Further Information