Medication Query - Harcourt Medical Centre

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Personal Details

Name

First Surname

Date of Birth

Address

Street Address Address Line 2 City Post Code

Contact Number

I have a query about medication

Please select the issue that best describes your query

I would like to order medication

Medication

Quantity

Name of medication:

Question relating to medication:

Which pharmacy would you like you prescriptions sending to?

If you get regular prescriptions, the Electronic Prescription Service (EPS) may be able to save you time by avoiding unnecessary trips to your GP. EPS makes it possible for your prescriptions to be sent electronically to the pharmacy or dispenser of your choice

Are you happy for us to nominate this pharmacy for your prescriptions

Yes

Choosing a pharmacy or dispensing appliance contractor to process your EPS prescription is called nomination. This means you’ll no longer have to collect a paper repeat prescription from your GP practice – instead, you can go straight to the nominated pharmacy or dispensing appliance contractor to pick up your medicines or medical appliances.

Please use the box below to tell us which medication you want to stop and why. If you have had side effects from the medication please list these. There are a number of medications that should not be stopped without medical advice such as steroids, heart medication, antidepressants and some pain-killers. If you are not sure please select “I have a question about medication” from the drop down box above, let us know the problem and we can advise you of the safest course of action.

Name of medication:

Reason you wish to stop:

Medication that are causing side effects

Medication Name

Side effects you have had

Use the boxes below to tell us about side effects you may be having form medication you have been prescribed. We can then review your medical notes and get back to you with appropriate advice.

Please tell us which medication(s) has not reached the pharmacy

Medication Name

Quantity

Which pharmacy have you tried to collect it from

Medication Quantity Query

Medication Name

Quantity

What would you like the quantity changed to

If the amount of medication you have received is incorrect, please use the boxes below to help us change the quantity to the correct amount.

Personal Details

I have a query about medication

Thank you for your feedback.