Medication Not on Repeat Request Form

This form is to be completed for any medication that is not on your Repeat Prescription.

Medication Not on Repeat
Please use format day/month/year e.g. 12/05/1979
Please let us know when we cannot call you. We cannot guarantee when we can call you. Enter N/A if we can call you at any time
It is more helpful if the name is copied from the original packaging
Enter the dosage of the medication
How often do you take the medication
Who prescribed the medication and when?
Reason that the medication is taken
Date the last medication was prescribed
Date the last medication was prescribed
Please provide any additional medication that will help the Pharmacist, GP, or Prescribing Nurse with your request
Consent