Inpatient Prescription Request

Patient Details

NHS Number *

INITIALS *

Allergies *

None

Penicillin and related antibiotics

Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs)

Other, please specifyOther, please specify

Upload Drug Chart

Maximum file size: 67.11MB

ITEM 1

Drug Name Form and Strength *

Directions for use by patient *

Quantity (Nearest Original Packs will be supplied) * Quantity (Nearest Original Packs will be supplied)

Second item? *

ITEM 2

Drug Name Form and Strength * Drug Name Form and Strength

Directions for use by patient *

Quantity (Nearest Original Packs will be supplied) * Quantity (Nearest Original Packs will be supplied)

Third item? *

ITEM 3

Drug Name Form and Strength * Drug Name Form and Strength

Directions for use by patient *

Quantity (Nearest Original Packs will be supplied) * Quantity (Nearest Original Packs will be supplied)

Fourth item? *

ITEM 4

Drug Name Form and Strength * Drug Name Form and Strength

Directions for use by patient *

Quantity (Nearest Original Packs will be supplied) * Quantity (Nearest Original Packs will be supplied)

Total Number of Items Requested *

Prescriber’s Full Name *

GMC Number *

Requesting Ward Staff

Full Name *

Email (Receive confirmation copy) *

Date

Signature *

Clear

Ear, Nose, & Throat

Infections & Minor Illness

Lifestyle

Skin

Vaccinations

Women's Health

Men’s Health

Aesthetics

Blood Pressure Check

Chickenpox

COVID-19 Vaccination

Cryotherapy

Earwax Removal

Family Planning

Flu Vaccination

Hair Loss

Hepatitis B

HPV

Menopause

Mole Check

Pneumococcal Vaccine

Private GP Services

Shingles Vaccination

Travel Vaccination Clinic

Vitamin B12 Treatment

Weight Management

Yellow Fever Vaccination

Book Appointment

Contact

Pricelist

NHS Services

Contraceptive Pill Repeat Supply

Ear Infection

(1-17 Years)

Impetigo Sores

(1+)

Infected Bug Bites

(1+)

NHS Cardiovascular Heath Check

NHS Stop Smoking Support

Shingles Rash

(18+)

Sinusitis

(12+)

Sore Throat

(5+)

Urine Infection

(Women 16-64 Yrs)

Private Services

Cardiovascular Heath Check

Erectile Dysfunction Treatment

Period Delay

Weight Loss Pre-Assessment

Book Appointment

Contact

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Get it on Play Store

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Patient Details

ITEM 1

ITEM 2

ITEM 3

ITEM 4

Requesting Ward Staff