Acute Medication Requests - Sandy Lane Surgery

Non-urgent advice: Patient Notice

Please fill in the form if you take a medication that is not on your repeat list.

The clinicians need all the following information to be able to process your request accurately; if the form is not fully completed your request will be denied.

Clinicians aim to complete these requests within 48 hours.

Please fill in a form for each item you require.

Your Details

Full Name

First Last

Date of Birth

Contact Number Optional

Enter Email Optional Confirm Email Optional

Medication Required

What medication do you require?

Who previously issued this medication?

i.e GP or hospital consultant or specialist

Do you suffer from any allergies? If yes, what?

Is it possible you could be pregnant?

Yes

Due to coronavirus, your prescription MUST be sent to a pharmacy. which pharmacy would you like it to go to?

Would you like this medication to go on your repeat list?

Yes

Strength and Dose

Reasons for taking this medication

i.e symtoms

Date you last had this medication

Phone Optional

This field is for validation purposes and should be left unchanged.