Prescription Request (Under 16)

This form is to request medication for under 16s only. You can request medication that you currently have on repeat or for an acute prescription.

Acute requests are for medication that you may or may not have had before and does not appear on your repeat medication list.

Please do not add information that is not related to this medication request.

Prescription Request (Under 16)

If you are human, leave this field blank.

About Your Child

Full Name: *

Date of Birth: *

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

Your Phone Number:

Your Email Address: *

Any responses we send will go to this email address.

Please specify the type of request: *

Repeat Prescription Request

Acute Prescription Request

Medication Required

Item Description

Strength

Quantity

Item Description

Strength

Quantity

Item Description

Strength

Quantity

Item Description

Strength

Quantity

Item Description

Strength

Quantity

Item Description

Strength

Quantity

Acute Prescription Request Only

Have you had this medication before? *

Yes

No

Please specify when you first had this medication: *

Please specify who prescribed this medication to you: *

Why do you require this medication? *

Would you like this medication added to your repeat medication list? *

Yes

No

I have nominated a pharmacy and will arrange my collection from the pharmacy.

I need to nominate a pharmacy for collection.

Nominate a Pharmacy

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *