Prescriptions: Pill check + COPD + Medication review

This form will help us review your COPD, contraceptive pill & any other medications. 

You will need an up to date weight and blood pressure. 

Information on various contraceptive options can be found below: 

This form also will ask you a number of questions about your COPD. It is important that this is done at least yearly to ensure we are keeping track of your symptoms. 

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.
Prescriptions: Pill check + COPD + Medication review

Some medical conditions can mean hormonal contraception is not a safe option. Please answer the following questions below about your own health and family history.

This could be inbetween your periods if you have a regular cycle, or after sex
e.g. 120/80 (Upper valve/Lower value). If you are unable to provide your blood pressure reading then you will need to attend an appointment at the surgery for a blood pressure check before your prescription can be issued.
In Kg or Stones & lbs
Medication Review
This relates to all your medications if you are on more then just the oral contraceptive. Please state the medication and the side effect. E.g. Paracetamol: Constipation
If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.
Please note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.
Declaration
Chronic Obstructive Pulmonary Disease (COPD) review
Ignore question if your cough is dry

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


Local Services, Let
Local Services, Let