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Over the Counter Medications
Please complete this form if you have concerns about a change to your repeat prescription.
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1
Name
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First Name
Last Name
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2
Date of Birth
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Date
Day
Month
Year
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3
Email
example@example.com
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4
I am concerned about a medication which has been
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stopped from my regular repeat list
declined as an acute medication request
changed to a different brand or preparation
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5
Name of medication
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6
Dose of medication
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7
Please explain your concerns and your reasons for these concerns:
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8
Can we let you know the outcome of the review by text message?
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9
Phone Number
Area Code
Phone Number
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