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)

About Your Child

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Please specify the type of request: *

Medication Required

Item Description
Strength
Quantity

Acute Prescription Request Only

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

Nominate a Pharmacy