Return of
Medication
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Return of Medication
During the COVID-19 pandemic and to ensure your safety and the safety of pharmacy staff please notify us in advance that you wish to return medication which is no longer required. Please complete the following form and we will ring you to agree with you a date and time when you can return these medicines. To support pharmacy staff please return medicines in a clear bag and package any controlled drugs separately.
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    Who are you returning the Medication on behalf of?
    MyselfSomeone else

    Name *

    Mobile Number *

    Email *

    Why is this Medication being returned? *

    Was this Medication dispensed by Christchurch Pharmacy? *
    YesNo

    Patient Name *

    Mobile Number *

    Email

    Why is this Medication being returned? *

    Your relationship to Patient *

    Your Name *

    Your Mobile Number *

    Was this Medication dispensed by Christchurch Pharmacy? *
    YesNo

    Please explain why you are returning this Medication to Christchurch Pharmacy and not the Pharmacy it was dispensed from *

    How many items/packs are you returning? *

    Are you returning any controlled drugs? *
    YesNo

     

    Controlled Drug

    Name *

    Form *

    Strength *

    Quantity *

     Remove

     Add another Controlled Drug