Acute (not on Repeat) Prescription Request Form

Please only use this form to request 'one-off medications' only if you have been prescribed the medication within the last 6 months by the practice - EXCLUDING ANTIBIOTICS

Your request will be subject to a doctors evaluation and / or hospital documentation. You may require an appointment or telephone consultation before we are able to authorise and prescribe your request.

Name

Date Of Birth

Address

Telephone Number

Email Address

Drug Name

Drug Strength (e.g. 5mg)

Daily Dose (e.g. 1 tablet at night)

Reason for medication request

If you have been provided a 'Discharge Medication Summary' by the hospital, please upload the form using the file attachment button below

Nantgarw Road Medical Centre

Nantgarw Road Medical Centre

Acute (not on Repeat) Prescription Request Form

Acute (not on Repeat) Prescription Request Form