Medication Record

HELP US TO HELP YOU

To help us deal with your treatment, we keep a confidential record of the medicines we supply to you.  In order to enhance this record it would be helpful if you could supply the following information, which will be added to your medication record.
For a downloadable version of this form please click  here

 Do you suffer from any of the following: -
 

·                   High blood pressure

·                   Heart attack

·                   Stroke

·                   Angina

·                   Heart failure

·                   Diabetes

·                   Thyroid disease

·                   Epilepsy

·                   Coeliac disease

·                   Ulcerative colitis or Crohn’s  disease

·                   Gastric or duodenal ulcer

·                   Liver  failure

·                   Kidney disease

·                   Cancer

·                   Arthritis
 

 Do you hold an exemption from prescription charges?

If so when does this exemption expire?

(please produce your exemption certificate if applicable when handing in this form)

………………………………………………………………………………

 Full Name ……………………………                Doctor………………….

 Address ……………………………...

               . …………………………….

Tel No.     ...................................

 Signature …………………………….

Please return this form to the Health Centre Pharmacy