Medication Review

We review medication on a repeat prescription either six monthly or annually and wherever possible the clinical pharmacist or doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due please use this form.

Medication Review

Medication Review

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Named GP (if known):

Do you have any concerns or side effects from your medication?

Yes

No

Please specify:

Do you know when and how to take your medication?

Yes

No

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

Are you happy for the doctor to update your review date now?

Yes

No

*

I confirm that the information provided is accurate to the best of my knowledge