Prescription Request Form
Requested date:
-
Day
-
Month
Year
Date
Patient's name:
First Name
Last Name
Consultant's name:
First Name
Last Name
Last review date:
-
Day
-
Month
Year
Date
Last prescription:
Next booked appointment:
-
Day
-
Month
Year
Date
How many days of medication left:
Prescription to be picked up or delivered:
Pick-up
Delivery
If delivered, please confirm delivery address:
Street Address
Street Address Line 2
City
County
Postcode
Your prescription will be delivered by a Pharmalogic who will contact you to collect payment and arrange delivery. Please confirm your contact number below:
Telephone number
Prescription request details:
Please note - medication cannot be increased without an appointment.
For repeat ADHD medication only - please confirm your current blood pressure reading as of today:
Payment made:
Yes
No
Signature
Date Signed
-
Day
-
Month
Year
Date
The Therapy Company, Unit 9 Lockside Office Park, Lockside Road, Preston, PR2 2YS.
Submit
Submit
Should be Empty: