Medication review

*

Confirmation of consent for information about your/the patient’s health to be sent to the email address provided

Named GP (if known):

Has your GP asked you to book a medication review? *

Yes

No

Please specify the medications that you have been asked to contact us about: *

So that we can arrange a review, how many days of medication do you have left? *

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.

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

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