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ADHD (adult) repeat prescription request
This form is for patients who are requesting their ADHD medication having been initiated by the hospital
* Please allow 2 working days before collecting your prescription.
Patients require 6 monthly health observations
- BP
- Pulse
- Body weight/BMI
If you do not already have a blood pressure machine and a weighing machine please consider purchasing this otherwise complete these checks at reception.
This will be sent to your nominated pharmacist automatically. If you do not have a nominated pharmacist please nominate one or the surgery will send to the nearest one to your current abode
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* Indicates required question
The questions asked may feel sensitive. However, it is important that these questions are asked to ensure the surgery can make the best assessment. Your answers are completely confidential
YOUR DETAILS
Please include your latest personal details so that we can contact you if necessary
Your Full Name
*
Your answer
Your Date of Birth
*
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
Your answer
Your MOBILE number
*
If we need to contact you to clarify your answers
Your answer
Your EMAIL address
*
If we need to contact you to clarify your answers
Your answer
PRESCRIPTION: ADHD Medication Required
Please provide the name of the ADHD medication,
*
Please choose press enter between medication entries. i.e. paracetamol 500mg 1 tablets 4 times a day. 100 tablets.
Choose
METHYLPHENIDATE HYDROCHLORIDE
DEXAMFETAMINE SULFATE
LISDEXAMFETAMINE MESILATE
ATOMOXETINE
Please provide detail of the strength, dosage and quantity
*
i.e. 50mg 1 tablets 4 times a day. 100 tablets.
Your answer
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