<img src="https://christchurchhealthcentre.co.uk/wp-content/uploads/2020/06/christ-church-health-centre.svg" alt="Christchurch Health Centre" style="max-width: 300px;" />

<img src="https://christchurchhealthcentre.co.uk/wp-content/uploads/2020/06/christ-church-health-centre.svg" alt="Christchurch Health Centre" style="max-width: 300px;" />

Inpatient Prescription Request

Home » Inpatient Prescription Request

Inpatient Prescription Request

COST CENTRE

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 *

If you are human, leave this field blank.

LEARN ABOUT OUR ORGANIZATIONS

LEARN ABOUT OUR ORGANIZATIONS

Scroll To Top