Repeat Prescription Form | Healthcare4Kids

Repeat Prescription Request

Healthcare4Kids will be taking a break over the Christmas period and the office will be closed from end of Friday 22nd December until Tuesday 2nd January inclusive. Please be aware that the clinicians will also be on annual leave at this point and will not be available to answer emails or write prescriptions. Please plan ahead to avoid your child missing out on medication and make sure any medication requests are received by the team with plenty of time, especially taking into account the often slower postal service over the Christmas period. We always ask for 2 weeks’ notice but it is worth requesting it earlier on this occasion. Please allow 5 working days for one of our clinicians to check and write a script. If you need your script to be posted you will need to allow extra time for this. Please provide full details on this form; any anomalies or missing data, the clinician may refuse to fulfil the script causing a delay to your request.

Please let us know which clinician you saw last in clinic (Dr Jo Jones, Ellie Olivieri or Katherine Fricker) *

Patient's Official Name ie the name on their birth certificate or passport *

First

Last

Patient's Preferred Name

First

Last

Your Email *

Patient's DOB *

Age of Patient *

Full Address *

Postcode *

Medication, dose and when taken *

Date of Next Review (please provide details of your next review, if you do not know when your next review is please enter 'not known') *

Have you any concerns about the patient and the medication they are taking? *

If yes, please detail your concerns:

If you prefer to collect your script from Healthcare4Kids our opening hours are 9.30 to 2.30pm Monday to Friday with late openings until 5pm on Mondays, Wednesdays and Thursdays. Our address is Supersonic House, 23 Adelaide Road, Leamington Spa, CV31 3PD. Would you like to collect your script (if yes, we will be in touch when your script is ready to collect)? *

Collect
Post