Acute (not on Repeat) Prescription Request Form

Please only use this form to request 'one-off medications' you have been prescribed before and hospital recommendations.

Your request will be subject to a doctors evaluation and / or hospital documentation. You may require an appointment or telephone consultation before we are able to authorise and prescribe your request.

Please DO NOT request controlled drugs using this form, as these groups of medications require a consultation with a doctor.

Name

Date Of Birth

Address

Telephone Number

Email Address

Drug Name

Drug Strength (e.g. 5mg)

Daily Dose (e.g. 1 tablet at night)

Reason for medication request

If you have been provided a 'Discharge Medication Summary' by the hospital, please upload the form using the file attachment button below