Batch Prescribing Consent Form

No need to order your repeat medication from the surgery! Do you want to save time? Has your regular medication stayed the same for at least 6 months? Was your last hospital stay at least 6 months ago? If you have answered YES to ALL of the above questions please complete this form. Read the patient leaflet for more information.

Name

First Last

Date of birth

Phone number Optional

Enter Email Optional Confirm Email Optional

Name of your preferred pharmacy:

Do you pay for your prescriptions?

Yes

I would like to be considered for Batch Prescription Service.

Signature

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