Medication Not on Repeat Online Form

Form Completion

One form submission for each medication required

Please remember that it can take up to 48 hours, or 2 working days for the Practice to process your request; thereafter it can take another day for the Pharmacy to process.

Medication Not on Repeat

This form is to be completed for any medication that is not on your Repeat Prescription

Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email*
Telephone contact number*
Please let us know your main telephone contact number
When not to call*
Please let us know when we cannot call you. We cannot guarantee when we can call you. Enter N/A if we can call you at any time
Medication Name*
It is more helpful if the name is copied from the original packaging
Dosage*
Enter the dosage of the medication
How often taken*
How often do you take the medication
Prescriber*
Who prescribed the medication and when?
Reason*
Reason that the medication is taken
Date of last medication*
Date the last medication was prescribed
Date Format: DD slash MM slash YYYY
Date Medication runs out*
Let us know the date the medication is expected to run out
Date Format: DD slash MM slash YYYY
Additional Information
Please provide any additional medication that will help the Pharmacist, GP, or Prescribing Nurse with your request
Please enter the answer to the sum in the box below
Consent*
I agree to the privacy policy.
Signature*