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The Hollies Medical Practice NHS GP Surgery in Tamworth

Pharmacy

Important: For healthcare professional use only

This form is for healthcare professionals only. If you are a patient and would like to request a prescription, please use the prescription request form.

Pharmacy

Healthcare organisation: *

About the request

Request type: *

Request a new medication

Request a change to an existing medication

Notification of medication prescribed (for information only)

Prescription enquiry

Discharge enquiry

New medication (item 1)

Medication name: *

Dose: *

Quantity: *

Reason for prescribing: *

Do you need to add another item? *

Yes

No

New medication (item 2)

Medication name: *

Dose: *

Quantity: *

Reason for prescribing: *

Do you need to add another item? *

Yes

No

New medication (item 3)

Medication name: *

Dose: *

Quantity: *

Reason for prescribing: *

Do you need to add another item? *

Yes

No

New medication (item 4)

Medication name: *

Dose: *

Quantity: *

Reason for prescribing: *

Do you need to add another item? *

Yes

No

New medication (item 5)

Medication name: *

Dose: *

Quantity: *

Reason for prescribing: *

Change of medication (item 1)

Old medication name: *

Old medication dose: *

Old medication quantity: *

New medication name: *

New medication dose: *

New medication quantity: *

Reason for change: *

Do you need to change another medication? *

Yes

No

Change of medication (item 2)

Old medication name: *

Old medication dose: *

Old medication quantity: *

New medication name: *

New medication dose: *

New medication quantity: *

Reason for change: *

Do you need to change another medication? *

Yes

No

Change of medication (item 3)

Old medication name: *

Old medication dose: *

Old medication quantity: *

New medication name: *

New medication dose: *

New medication quantity: *

Reason for change: *

Do you need to change another medication? *

Yes

No

Change of medication (item 4)

Old medication name: *

Old medication dose: *

Old medication quantity: *

New medication name: *

New medication dose: *

New medication quantity: *

Reason for change: *

Do you need to change another medication? *

Yes

No

Change of medication (item 5)

Old medication name: *

Old medication dose: *

Old medication quantity: *

New medication name: *

New medication dose: *

New medication quantity: *

Reason for change: *

Notification of medication prescribed

Medication name: *

Dose: *

Quantity: *

Reason for prescribing: *

Prescription enquiry

Please provide details of your enquiry: *

Discharge enquiry

Discharge date: *

Please provide details: *

If you are human, leave this field blank.

The Hollies Medical Practice
Tamworth Health Centre
Upper Gungate
Tamworth
Staffordshire
B79 7EA

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01827 217799

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