E Contact Acute Prescriptions Request Form

PLEASE NOTE, THIS FORM SHOULD BE USED FOR REQUESTING ACUTE MEDICATION ONLY. ANY REQUESTS RECEIVED FOR REPEAT PRESCRIPTIONS WILL BE REJECTED WITH NO ACTION BEING TAKEN. PLEASE ALLOW THREE FULL WORKING DAYS (72 HOURS) FOR ACUTE PRESCRIPTIONS TO BE PROCESSED. REMEMBER TO TAKE WEEKENDS AND BANK HOLIDAYS INTO ACCOUNT.

Last Updated: 13/09/2023

Your Details

First Name *

Surname *

Date of Birth *

Phone Number *

Email Address *

MEDICATION REQUIRED

Item - eg Atenolol? *

Strength 1 - eg 50mg *

Quantity - eg 28 tabs *

Whom initially prescribed this item (practice/hospital/private consultant etc) *

Additional info e.g. extra medication needed as going away *

Preferred Pharmacy Name *

Preferred Pharmacy Post Code *

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.. *

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E Contact Acute Prescriptions Request Form

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