Prescriptions: Request acute medication

This form is for ALL acute medication requests including iron supplementation.

Please note that URGENT temporary issues of a prescription can be obtained from your local pharmacy.

Please outline below what acute prescription you require e.g. iron supplementation, inhalers, creams etc.

Please note this is NOT for REPEAT MEDICATIONS. If a repeat medication request comes through via this form it will be discarded. Find out how to request your repeat medications.

Over the counter medications

NHS England issued new guidance on conditions for which over the counter items should not routinely be prescribed in primary care. This means that your doctor, or other prescriber, will not routinely prescribe medicines for minor health conditions that can be purchased over the counter. Tips to reduce cost

Avoid brands and buy generic
Avoid cough and cold remedies as there is no evidence that these are effective
Buy from supermarkets over pharmacies as often cheaper
Keep cupboard stocked so you have it when required

In rare circumstances over the counter medications can be prescribed, but this is done on a case by case basis. The reasons for this need to be outlined on the form below.

NHS Over The Counter Leaflet (EXTERNAL PDF LINK)

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 3 working days to complete. Please DO NOT call before 3 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Prescriptions: Request acute medication

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

What medication would you like to request?Please note this form will ONLY be accepted if you have been on this medication before & it is NOT a request for antibiotics. If you would like to request these medications you must contact reception to make an appointment.

Please note if you are requesting an inhaler you must have either been prescribed it before or have a diagnosis of asthma. If not regarding an inhaler leave this question blank

I have a diagnosis of asthma

I have been issued an inhaler before

Please outline any further information for your request e,g. when you last took it & what is it for

Which pharmacy would you like your prescription to be sent

If other please state the pharmacy name & postcode

I understand that if this is a repeat medication request the form will be discarded and not actioned (see above on how to correctly request your repeat medications)

I confirm this is not a request for antibiotics or to arrange a telephone appointment & understand that if it is this form will be discarded.

If this medication can be bought over the counter then please explain why you are requesting a prescription for this:Please note that your request will be reviewed and a decision communicated to you via text. If no information is given for a medication which can be purchased over the counter then this form will be discarded.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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