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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.
Next
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.
Please note: Prescriptions for Circadin are now written on FP10HP (Green) prescriptions like the prescriptions you would normally get from your GP practice.
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):
Medication Name 1 and Strength Required:
*
Atomoxetine 10mg capsule
Atomoxetine 18mg capsule
Atomoxetine 25mg capsule
Atomoxetine 40mg capsule
Atomoxetine 60mg capsule
Atomoxetine 80mg capsule
Circadin (whole) 2mg tablet
Circadin (crushed) 2mg tablet
Concerta XL 18mg tablet
Concerta XL 27mg tablet
Concerta XL 36 mg tablet
Concerta XL 54mg tablet
Equasym XL 10mg capsule
Equasym XL 20mg Capsule
Equasym XL 30mg Capsule
Guanfacine (intuniv) 1mg tablet
Guanfacine (intuniv) 2mg tablet
Guanfacine (intuniv) 3mg tablet
Guanfacine (intuniv) 4mg tablet
Lisdexamfetamine (Elvanse) 20mg capsule
Lisdexamfetamine (Elvanse) 30mg capsule
Lisdexamfetamine (Elvanse) 40mg capsule
Lisdexamfetamine (Elvanse) 50mg capsule
Lisdexamfetamine (Elvanse) 60mg capsule
Lisdexamfetamine (Elvanse) 70mg capsule
Medikinet XL 10mg capsule
Medikinet XL 20mg capsule
Medikinet XL 30mg capsule
Medikinet XL 40mg capsule
Medikinet XL 50mg capsule
Medikinet XL 60mg capsule
Methylphenidate 5mg tablet
Methylphenidate 10mg tablet
Methylphenidate 20mg tablet
XaggitinXL 18mg tablet
XaggitinXL 27mg tablet
XaggitinXL 36 mg tablet
XaggitinXL 54mg tablet
Xenidate XL 18mg tablet
Xenidate XL 27mg tablet
Xenidate XL 36 mg tablet
Xenidate XL 54mg tablet
Other (Please State)
Please note: If your child is on melatonin capsules, the medication will 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):
*
Add more medications
Medication Name 2 and Strength Required:
Atomoxetine 10mg capsule
Atomoxetine 18mg capsule
Atomoxetine 25mg capsule
Atomoxetine 40mg capsule
Atomoxetine 60mg capsule
Atomoxetine 80mg capsule
Circadin (whole) 2mg tablet
Circadin (crushed) 2mg tablet
ConcertaXL 18mg tablet
Concerta XL 27mg tablet
Concerta XL 36 mg tablet
Concerta XL 54mg tablet
Equasym XL 10mg capsule
Equasym XL 20mg Capsule
Equasym XL 30mg
Capsule Guanfacine (intuniv) 1mg tablet
Guanfacine (intuniv) 2mg tablet
Guanfacine (intuniv) 3mg tablet
Guanfacine (intuniv) 4mg tablet
Lisdexamfetamine (Elvanse) 20mg capsule
Lisdexamfetamine (Elvanse) 30mg capsule
Lisdexamfetamine (Elvanse) 40mg capsule
Lisdexamfetamine (Elvanse) 50mg capsule
Lisdexamfetamine (Elvanse) 60mg capsule
Lisdexamfetamine (Elvanse) 70mg capsule
Medikinet XL 10mg capsule
Medikinet XL 20mg capsule
Medikinet XL 30mg capsule
Medikinet XL 40mg capsule
Medikinet XL 50mg capsule
Medikinet XL 60mg capsule
Methylphenidate 5mg tablet
Methylphenidate 10mg tablet
Methylphenidate 20mg tablet
XaggitinXL 18mg tablet
XaggitinXL 27mg tablet
XaggitinXL 36 mg tablet
XaggitinXL 54mg tablet
Xenidate XL 18mg tablet
Xenidate XL 27mg tablet
Xenidate XL 36 mg tablet
Xenidate XL 54mg tablet
Other (Please State)
Other medication 2 (please state here):
Dose / Frequency for medication 2:
Medication Name 3 and Strength Required:
Atomoxetine 10mg capsule
Atomoxetine 18mg capsule
Atomoxetine 25mg capsule
Atomoxetine 40mg capsule
Atomoxetine 60mg capsule
Atomoxetine 80mg capsule
Circadin(whole) 2mg tablet
Circadin(crushed) 2mg tablet
ConcertaXL18mg tablet
ConcertaXL 27mg tablet
ConcertaXL 36 mg tablet
ConcertaXL 54mg tablet
EquasymXL 10mg capsule
EquasymXL 20mg
Capsule EquasymXL 30mgCapsule
Guanfacine (intuniv) 1mg tablet
Guanfacine (intuniv) 2mg tablet
Guanfacine (intuniv) 3mg tablet
Guanfacine (intuniv) 4mg tablet
Lisdexamfetamine(Elvanse) 20mg capsule
Lisdexamfetamine(Elvanse) 30mg capsule
Lisdexamfetamine(Elvanse) 40mg capsule
Lisdexamfetamine(Elvanse) 50mg capsule
Lisdexamfetamine(Elvanse) 60mg capsule
Lisdexamfetamine(Elvanse) 70mg capsule
MedikinetXL 10mg capsule
MedikinetXL 20mg capsule
MedikinetXL 30mg capsule
MedikinetXL 40mg capsule
MedikinetXL 50mg capsule
MedikinetXL 60mg capsule
Methylphenidate 5mg tablet
Methylphenidate 10mg tablet
Methylphenidate 20mg tablet
XaggitinXL18mg tablet
XaggitinXL27mg tablet
XaggitinXL36 mg tablet
XaggitinXL54mg tablet
XenidateXL 18mg tablet
XenidateXL 27mg tablet
XenidateXL 36 mg tablet
XenidateXL 54mg tablet
Other (Please State)
Other medication 3 (please state here):
Dose / Frequency:
Medication Name 4 and Strength Required:
Atomoxetine 10mg capsule
Atomoxetine 18mg capsule
Atomoxetine 25mg capsule
Atomoxetine 40mg capsule
Atomoxetine 60mg capsule
Atomoxetine 80mg capsule
Circadin(whole) 2mg tablet
Circadin(crushed) 2mg tablet
ConcertaXL18mg tablet
ConcertaXL 27mg tablet
ConcertaXL 36 mg tablet
ConcertaXL 54mg tablet
EquasymXL 10mg capsule
EquasymXL 20mg
Capsule EquasymXL 30mgCapsule
Guanfacine (intuniv) 1mg tablet
Guanfacine (intuniv) 2mg tablet
Guanfacine (intuniv) 3mg tablet
Guanfacine (intuniv) 4mg tablet
Lisdexamfetamine(Elvanse) 20mg capsule
Lisdexamfetamine(Elvanse) 30mg capsule
Lisdexamfetamine(Elvanse) 40mg capsule
Lisdexamfetamine(Elvanse) 50mg capsule
Lisdexamfetamine(Elvanse) 60mg capsule
Lisdexamfetamine(Elvanse) 70mg capsule
MedikinetXL 10mg capsule
MedikinetXL 20mg capsule
MedikinetXL 30mg capsule
MedikinetXL 40mg capsule
MedikinetXL 50mg capsule
MedikinetXL 60mg capsule
Methylphenidate 5mg tablet
Methylphenidate 10mg tablet
Methylphenidate 20mg tablet
XaggitinXL18mg tablet
XaggitinXL27mg tablet
XaggitinXL36 mg tablet
XaggitinXL54mg tablet
XenidateXL 18mg tablet
XenidateXL 27mg tablet
XenidateXL 36 mg tablet
XenidateXL 54mg tablet
Other (Please State)
Other medication 4 (please state):
Dose / Frequency for medication 4:
Post to local pharmacy / Post Prescription to home address:
*
Post to local pharmacy
Post to 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 location 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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Alder Hey Children's Charity
Home
Your Stay
Your Stay
Before You Visit
Before You Visit
Getting to Alder Hey Children's Hospital
Getting to Dewi Jones
Getting to our community sites
What to bring
Change your appointment
When You Arrive
When You Arrive
Our atrium
Getting around
While You're Here
While You're Here
Your ward
Outpatients
Having surgery
Pharmacy
Spiritual care
Alder Hey arts
Facilities at Alder Hey
Local facilities
Ronald McDonald House
Share Your Feedback
Share Your Feedback
Messages of thanks
PALS - for queries and concerns
Complaints
Helpful Information for Young People
Other Information
Other Information
Patient information leaflets
Duty of candour
Overseas visitors
Subject access requests
Visitors and relatives charter
Alder Hey consent policy
Equality and diversity
Our Services
COVID-19 Information Hub
A Healthier Future
A Healthier Future
Alder Hey in the Park
Alder Hey in the Park
Our Hospital
The Speakman Building
Our Clinical Research Facility
Our Innovation Hub
Our Alder Centre
Springfield Park
The Department of International Child Health
Our Green Plan
Growing in Partnership
Growing in Partnership
Our Partners
Neonatal Care
Congenital Heart Network
Groundbreaking Research
Groundbreaking Research
Children & young people at the heart
Institute in the Park
NIHR Alder Hey Clinical Research Facility
Children's Nursing Research Unit
Paediatric Medicines Research Unit
Better, Safer Medicines
Infection
Rheumatic Disorders
Cancer Treatment
Research Clinics
Future Researchers
Pioneering Innovation
Education
Education
Alder Hey Academy
Paediatric Training
Strong Foundations
Strong Foundations
Outstanding Care
Best People
Our People
Our People
Patient referrals
Join Us
Join Us
Work at Alder Hey
Work at Alder Hey
Current vacancies
Nursing
Moving to Liverpool
Clinical work placements
Our recruitment process
Work experience
Volunteering
Volunteering
Volunteer Application
Become a Governor
Become a Member
Join Our Forum
Join Our Forum
The Forum @ Alder Hey application form
Support Our Charity