Neurodevelopmental Paediatrics Repeat Prescription Request Form

Do NOT complete this form if your local GP has agreed to 'shared care'. Please request medications on the shared care agreement through your GP. You will know if your child is on shared care if you have received a letter about this.

Is your child under the care of the Developmental Paediatrics team? *

Yes No

Please click the next button below to continue to the form

Only medications managed by the Developmental Paediatric team can be ordered using this form. If you need to order other medications managed by other specialties, speak to your clinician's PCO.

Repeat Prescription Request Form

Please note - this is for repeat prescriptions only

Please complete this form to request your child's medication. Complete as much of the information as accurately as possible. A delay will be caused if we need to clarify this information. We aim to send out your prescription to your home address or local pharmacy within 2 weeks of making the request.

Your Child's Name: *

AH Number:

D.O.B (DD/MM/YY): *

Your name: *

Relationship to Child: *

1st line of address: *

Postcode: *

Contact Telephone No.: *

Contact email address: *

Medication Name 1 and Strength Required: *

Other medication 1 (please state here):

Dose / Frequency for medication 1 (how much and how often your child takes this medication i.e.1 tablet twice a day at breakfast and lunch): *

Add more medications

Medication Name 2 and Strength Required:

Other medication 2 (please state here):

Dose / Frequency for medication 2:

Medication Name 3 and Strength Required:

Other medication 3 (please state here):

Dose / Frequency:

Medication Name 4 and Strength Required:

Other medication 4 (please state):

Dose / Frequency for medication 4:

Post to local pharmacy / Post Prescription to home address: *

Prescriptions for melatonin or circadin are dispensed by Alder Hey Pharmacy and medication sent directly to your home address.

Posting your child's prescription directly to your local pharmacy will speed up how long it will take to get your child's medication ready. They will be able to order in stock of the medication if they need to. They may be able to dispense the medication ready for you to collect, reducing the time you wait for your child's medication.

Pharmacy name:

Pharmacy Address:

Pharmacy Postcode:

I give my consent for my child's prescription to be sent to the pharmacy/home address I have stated above. I confirm that the details I have provided are correct. *

I consent

Additional comments:

For admin use only

Logged onto database

Date:

By:

Last clinic appointment:

Last script

Drug:

Quantity:

Drug:

Quantity:

Next clinic appointment:

Data checked by:

If you have completed all of the relevant sections of this form, please click the submit button below.

A copy of this form will be sent to the email address you provided. Please check your junk folder and mark the email as safe for future requests.

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Neurodevelopmental Paediatrics Repeat Prescription Request Form

Repeat Prescription Request Form

*Please note* - this is for repeat prescriptions only

For admin use only

If you have completed all of the relevant sections of this form, please click the submit button below.

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Please note - this is for repeat prescriptions only