Somerville Medical Centre

Somerville Medical Centre

69 Gorsey Lane, Wallasey, Merseyside, CH44 4AA

Current time is 22:08 - Sorry, we're closed

NHS

Telephone: 0151 638 9333

wiccg.gatekeeperN85024@nhs.net

Prescription Request Forms

Prescription Alignment Form

 

We would like to help you to get your prescriptions running together.  In order to do this we would like you to count up how many tablets you have left for each item on your prescription and complete the table below.  The best time to do this is at the end of the day when all the day’s tablets have been taken.

 

We cannot put ‘when necessary’ medication on this scheme – they have to be ordered separately when you need them.

 

Patient Name ……………………………. Date of Birth ………………

Date Form Completed ………………..

 

Drug Name

 

Dose Number of Tablets Left
     
     
     
     
     
     
     
     
     

 

PLEASE MAKE SURE THAT YOU HAVE 7 DAYS SUPPLY LEFT WHEN YOU HAND IN THIS FORM WITH YOUR REPEAT PRESCRIPTION REQUEST STATING WHICH PHARMACY YOU USE.

 

  • A prescription will be issued with enough of each item so that, when added to those you already have, they will all run out at the same time.

 

  • Future prescriptions for all medications will be for the same as your usual amount.