Repeat Prescription Request - Prescription to be sent to client address– ISC-CARE LIMITED
This form is for existing clients of ISC-CARE requesting their prescription to be sent to their address.
Please confirm that you want your prescription to be delivered directly to your address
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Prescription delivered to your address
Please confirm the date that your current medication will run out
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Month
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Day
Year
Date
Client Details Section
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Email
*
example@example.com
Baseline Health Information
Blood Pressure (mmHg)e.g., 120/69
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Heart Rate (beats per minute)e.g., 70
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Weight (kg)e.g., 53
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Current Medication and Dosing
What ADHD medication are you prescribed?(e.g., Elvanse)
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What is your current daily dose?(e.g., 60mg)
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How many days are you requesting?(Maximum 28 days)
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What address would you like the prescription/medication sent to?
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Additional Information
Are you experiencing any side effects and Is there anything else you would like us to know before we process your prescription?
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Consent and Confirmation
I have had a medication review within the last 6 months. I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may affect the safety and appropriateness of my treatment.
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I confirm the above statements
Signature
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My Products
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Repeat Prescription
Repeat prescription request
£35.00
£
35.00
Quantity
1
2
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8
9
10
Item subtotal:
£0.00
£
0.00
Payment Methods
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
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Should be Empty: