Prescriptions: New patient medication request

Please complete this form if you are a new patient at the practice and would like to request your repeat medications.

Depending on what clinical system your previous practice used we may need to see evidence of your medication prescription. This could be a recent (in last 2 months) prescription slip or a letter from your GP/Consultant.+

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

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.

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Who was your old GP surgery (Name & Address)

Please note down below your repeat medications including: Name, dose, & how many times a day.

Do you have any recent (last 2 months) prescription slips or GP/consultant letters confirming your repeat prescription?

I confirm I am happy to be contacted by the surgery (text or call) on the mobile number provided if deemed necessary and that the information given in this form is accurate.

If approved how would you like to collect your prescription?

I understand that if my old surgery used a different clinical system to my ours it may well take longer to confirm my medication list and this will delay their issue.

Which pharmacy would you like to collect your prescription from? (Due to coronavirus we do no accept collection from reception)

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.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

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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