Neurodevelopmental Paediatrics Repeat Prescription Request Form

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

Yes No

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.

Do you have less than 3 weeks of medication left? *

Yes No

Unfortunately we will not be able to process your order if we receive it, please order when your child has 3 weeks of medication left

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.

Please click the next button below to continue to the form

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 requested location 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: *

Mobile No. (a text will be sent out once your prescription has been posted): *

Contact email address: *

Telephone No. (Optional):

Please select the medications your child is prescribed. If it is not listed, please select 'other' and specify what this is.

Medication Name 1 and Strength Required: *

Please note: If your child is on any other forms of melatonin which are not slenyto or circadin, the medication will be prepared by our in house pharmacy and sent directly to your home address. This usually takes longer and will be sent separately to any other medication requested.

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): *

Additional information relating to medication order:

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:

Please nominate a pharmacy you would like your prescription to go to. Please note, we are only able to deliver to pharmacies within the Southport, Sefton, Knowsley or Liverpool locality. Some online pharmacies are based outside of the area and we are unable to deliver to them.

Pharmacy name: *

Pharmacy Address: *

Pharmacy Postcode: *

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

I consent

All prescriptions will be hand delivered by courier to your local pharmacy. We will send you a text once it has been delivered. Please ensure you have provided us with your up to date mobile number to enable us to do this.

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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