Request a prescription

First name

Surname

I confirm that I have read and understand the repeat prescription guidelines above

Request date

Typically today’s date

Date of birth

Contact number

Your mobile or telephone number

Postcode

NHS number or hospital number

This can be found on a previous hospital letter

Date of last consultation

Date of last supplied prescription

Name of drug

Dose of drug

Dosing frequency

How often you take the drug

GnRHa drugs

I am not on this drug

I am and not pregnant and using contraception (eg condoms)

I am not at risk of pregnancy or requiring contraception (state why below)

A GnRHa (eg syneral, decapeptly, zoladex, prastap) is not a licenced contraceptive—if you are requesting a drug from this group, you must confirm that you not currently pregnant and using contraception

Reason you are not at risk of pregnancy

Complete only if you ticked the third option above

Drug allergies

List all known drug allergies—if none, write ‘none’

Have you ever had a heart attack, stroke (CVA/TIA) or blood clot (VTE/DVT)?

Yes

No

Have you ever had breast cancer?

Yes

No

Recent blood pressure reading

Please provide a blood pressure reading taken within the last two months—this can be done at home, your GP surgery or a pharmacy

I confirm all the details above are correct