Medication review

Please select the surgery you are registered with: *

Do you require a translator?

Yes

No

Does your request relate to a specific drug, or all of your medication?

A specific drug

All of my medication

Do you want your medication to be sent now?

Yes

No

Do you have any concerns or side effects from your medication?

Yes

No

Please specify:

Do you know when and how to take your medication?

Yes

No

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

Are you happy for the doctor to update your review date now?

Yes

No

Any further information:

I confirm that the information provided is accurate to the best of my knowledge

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