Prescription Request

IMPORTANT: REQUESTS SHOULD BE MADE AT LEAST 14 DAYS BEFORE YOUR PRESCRIPTION IS DUE. IF YOU MAKE A REQUEST WITHIN 14 DAYS OF WHEN YOUR PRESCRIPTION IS REQUIRED, YOUR MEDICATION MAY BE DELAYED.

Repeat Prescription Request Fee: £25.00

All prescriptions with the exception of topical creams and Medicinal Cannabis will be sent to our Pharmacy  – Pharmacierge by default.

Medicinal Cannabis prescriptions will be sent to PCCA.

Topical Creams will be sent to: PCCA

Repeat Prescription Request Cost:  £25.00
A payment link will be sent to you by email once we have received the completed request form.
 
The prescription request will be completed once the £25.00 fee has been paid.

REQUESTS SHOULD BE MADE AT LEAST 14 DAYS BEFORE YOUR PRESCRIPTION IS DUE.

If you have not been seen for a follow up appointment in the last 3 months, you will require a follow up appointment before future prescriptions can be issued. 

* Indicates required question

    Please select the name of your Consultant*

    Full Name of Patient*

    Have you had a follow up appointment within the last 3 months? *

    For follow up appointments please visit : https://www.londonpainclinic.com/online-booking/

    Postal Address*

    Date of Birth*

    Contact Telephone Number*

    Email Address*

    Name of Medication, Dose, Frequency and Total: Eg Tapentadol 50 mg, four times per day, 4 weeks supply, Total 112 Tablets*

    Where the prescription is to be sent to (The selected pharmacy will dispense the medication to your home address):*

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    Please note, all information given on this proforma remains confidential and is held securely by London Pain Clinic in accordance with GDPR and the DPA 2018. The information is used to help simplify your assessment and to enable maximum time to be spent on examination and discussion during your assessment. It is no way a substitute for a full consultation and examination. Thank you for taking the time to complete this questionnaire.

    Please note that the outcome will be based on the information you have provided. Therefore, London Pain Clinic accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.