NEW SURGERY, PENCOED

Primary Care Centre, Min-Y-Nant, Pencoed, Bridgend, CF35 6YP

01656 860343

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Acute (not on Repeat) Prescription Request Form

Acute (not on Repeat) Prescription Request Form

Please only use this form to request 'one-off medications' you have been prescribed before and hospital recommendations.
Your request will be subject to a doctor's evaluation and / or hospital documentation. You may require an appointment or telephone consultation before we are able to authorise and prescribe your request.

Name

Date Of Birth

Address

Telephone Number

Email Address

Drug Name

Drug Strength (e.g. 5mg)

Daily Dose (e.g. 1 tablet at night)

Reason for medication request

If you have been provided a 'Discharge Medication Summary' by the hospital, please upload the form using the file attachment button below

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NEW SURGERY, PENCOED

Primary Care Centre
Min-Y-Nant, Pencoed
Bridgend
CF35 6YP

01656 860343

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