Repeat prescription form

Important information: We’re aware there are national shortages of some ADHD medications. This is a changing situation; therefore some drugs may go out of stock after we have prescribed your medication. We are working hard to ensure we continue to supply your medication. If you can’t obtain methylphenidate or lisdexamfetamine (Elvanse) and your child can take a break off the medication, then please do so. Please DO NOT take breaks from Guanfacine (Intuniv) and Atomoxetine.

The latest issues are with Methylphenidate 12 hour release preparations.This includes Concerta, Xaggitin, Xenidate, Delmosart, Affenid and Matoride.

These are likely to be out of stock for several months. We will update this time frame as soon as we know anything more specific.

BEFORE submitting this request if your child is normally taking Methylphenidate 12 hour release preparations.This includes Concerta, Xaggitin, Xenidate, Delmosart, Affenid and Matoride.

You may choose to check with community pharmacies to see if they have this stock available in store.

If they do, please continue to submit the request and let us know in the ‘additional information section’ that you have confirmed the pharmacy has stock of this medication and a prescription will be issued.
If they do not, and your child is able to take a break from this medication please do so.
If they do not and are unable to take a break, please submit the request but note we will issue a prescription for an alternative medication and a letter to explain any changes.

Is your child under the care of the Developmental Paediatrics team?(Required)

Yes

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?(Required)

Yes

Is there a possibility the person receiving this medication may be pregnant?(Required)

Yes

Please contact your clinical team to discuss future prescriptions.

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 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 3 weeks of making the request.

Your child's name(Required)

First Last

Your Child's Hospital Number (AH Number)

Your child's date of birth(Required)

Your name(Required)

First Last

Relationship to child(Required)

Address(Required)

Address Line 1 Address Line 2 ZIP / Postal Code

Mobile phone number(Required)

a text will be sent out once your prescription has been posted

Email address(Required)

Telephone number

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(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)(Required)

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

Add a second medication

Medication Name 2 and Strength Required(Required)

Other medication 2 (please state here)(Required)

Dose / Frequency for medication 2

How much and how often your child takes this medication i.e.1 tablet twice a day at breakfast and lunch.

Add more medications

Add a third medication

Medication Name 3 and Strength Required(Required)

Other medication 3 (please state here)(Required)

Dose / Frequency for medication 3

How much and how often your child takes this medication i.e.1 tablet twice a day at breakfast and lunch.

Add more medications

Add a fourth medication

Medication Name 4 and Strength Required(Required)

Other medication 4 (please state here)(Required)

Dose / Frequency for medication 4

How much and how often your child takes this medication i.e.1 tablet twice a day at breakfast and lunch.

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(Required)

Pharmacy address(Required)

Address Line 1 Address Line 2 City Post Code

Confirmation(Required)

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

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.

Shortages of some ADHD medications

Please note