Repeat Prescription Request - Prescription to be sent to client address– ISC-CARE LIMITED
This form is for existing clients of ISC-CARE requesting their prescription to be sent to their address.
Please confirm that you want your prescription to be delivered directly to your address
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Prescription delivered to your address
Please confirm the date that your current medication will run out
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Month
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Day
Year
Date
Client Details Section
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Email
*
example@example.com
Baseline Health Information
Blood Pressure (mmHg)e.g., 120/69
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Heart Rate (beats per minute)e.g., 70
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Weight (kg)e.g., 53
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Current Medication and Dosing
What ADHD medication are you prescribed?(e.g., Elvanse)
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What is your current daily dose?(e.g., 60mg)
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How many days are you requesting?(Maximum 28 days)
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What address would you like the prescription/medication sent to?
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Additional Information
Are you experiencing any side effects and Is there anything else you would like us to know before we process your prescription?
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Consent and Confirmation
I have had a medication review within the last 6 months. I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may affect the safety and appropriateness of my treatment.
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I confirm the above statements
Signature
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My Products
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Repeat Prescription
Repeat prescription request
£
33.50
Quantity
1
2
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10
Item subtotal:
£
0.00
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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