Medication Review

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Personal Details

This form should not be used for Repeat Medication Requests.

We review any regular medication on a repeat prescription annually and wherever possible the clinical pharmacist or doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due please use this form.

Please double check you've entered the correct email address
May be used to identify you
Efficacy of medicine/s
e.g., Ventolin inhaler two times a day
Change in Medication
Additional Information
Take three BP reading at 5 minutes interval and record the lowest reading (where both the numbers are low). Input the figure as 120/80 along with date when BP was recorded.
List Height and Weight with metrics i.e., 5.8 ft or 176.5cms. Weight as 60Kg or 132.27 Lbs or 9.44 stones.
Enter number of cigarettes per day

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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