Repeat Prescription Request – Online GP Service

Repeat Prescription

Ensure Safer Prescribing

GUIDANCE

The following form is for existing Dokta patients to order repeat prescriptions for medication we have previously prescribed. New medications need to be discussed in an appointment.

Please complete as fully as possible. Your prescription will be issued within 24 hours of receipt.

NB. Not to be used for antibiotics or controlled drugs.

Patient Details

First Name

Last Name

Date of Birth

Medication Details

Each medication is clinically reviewed before being issued. In some cases, you may be asked to make an appointment to discuss your request.

1. Medication Name

2. Medication Name

3. Medication Name

4. Medication Name

5. Medication Name

6. Medication Name

1. Dose

2. Dose

3. Dose

4. Dose

5. Dose

6. Dose

1. Frequency

2. Frequency

3. Frequency

4. Frequency

5. Frequency

6. Frequency

1. Duration

2. Duration

3. Duration

4. Duration

5. Duration

6. Duration

Blood Pressure Measurement

Please enter a latest blood pressure if you are requesting blood pressure medicine, contraception or HRT. You can also do this separately by sending an email to: info@dokta.co.uk.

Systolic BP (top number)

Diastolic BP (bottom number)

Beneficial Response (Optional)

Explain any benefits you have experienced from taking this medication.

Benefits

Side-effects

Describe any side-effects you think any medication may be causing?

Side-effects

New Medical History

Have you been diagnosed with any new medical problems or changed any regular medication since your last review?

Any new medical problems?

Yes

If yes, which one(s)

Started any new medication?

Yes

If yes, which one(s)

Stopped any medication?

Yes

If yes, which one(s)

Safety check

Let us know if you have experienced any of the following:

Give details:

Delivery

Choose delivery of medication or prescription options.

NB. Emailed images of prescriptions with signatures are not legal or acceptable to pharmacies.

I would like:

Medication to be delivered

An electronic prescription code so that I can choose my own pharmacy

A paper prescription to be posted to me (2 working days)

Different Delivery Address

Only complete if you would like delivery to a different address to your home address

Address

Address Line 1

Address Line 2

Town/City

County

Post Code

Country

Consent

In order to continue with treatment

The information I have provided is complete and correct

Yes

I understand this is not an emergency service

Yes

I consent to a clinician reviewing my request

Yes

I understand approval is not guaranteed

Yes

Repeat Prescription Fee

Payment Item

Price: £25.00

Pay with Card (Stripe)