Carer Repeat Prescription Request ONLY - West Quay Medical Centre

This form has been created to enable Carers only to request repeat prescriptions for people they care for who are registered with the surgery.

This is due to the limitation of the NHS Wales App where Carers cannot currently order repeat medication for the person they care for.

THIS FORM SHOULD NOT BE USED TO SUBMIT MEDICATION REQUESTS WHICH ARE NOT ON A REGULAR REPEAT.
Please allow 72 hours for prescription processing (Mon-Fri) and extra time for your nominated pharmacy to dispense the medication.

We advise you to order any repeat medication 7 days before it is due. This will allow the surgery time to process the prescription and for the pharmacy to prepare and dispense it. Any requests which are submitted earlier than 7 days will not be processed.

Wherever possible we will send it to your local nominated pharmacy. If you do not have a designated pharmacy and would like your prescription to be sent to them please let us know who your chosen pharmacy is when you make your request.

Patient's Full Name

Patient's Date of Birth

Patient's Registered Address

Carer's Full Name

Carer's Contact Number

Attach copy of repeat slip form to avoid completing information below

Medication Required

Please list all medications required to include Name, Strength / Dosage and quantity required. You can request up to 10 items using this form. Please list individual items below

Item 1 - Medication Name, Strength / Dosage, Quantity

Item 2 - Medication Name, Strength / Dosage, Quantity

Item 3 - Medication Name, Strength / Dosage, Quantity

Item 4 - Medication Name, Strength / Dosage, Quantity

Item 5 - Medication Name, Strength / Dosage, Quantity

Item 6 - Medication Name, Strength / Dosage, Quantity

Item 7 - Medication Name, Strength / Dosage, Quantity

Item 8 - Medication Name, Strength / Dosage, Quantity

Item 9 - Medication Name, Strength / Dosage, Quantity

Item 10 - Medication Name, Strength / Dosage, Quantity

Collection Point i.e. name of chemist

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy. This information is not shared with any third party organisations. This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form