Repeat Prescription Request

(In accordance with NICE Guidelines for ADHD Management)

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Full Name *

Date of Birth

Name of your Consultant

Email Address *

Phone Number

GP Name & Practice Address

How would you like your prescription to be sent? *

• To The Good Pharmacist
• To your Home Address

If selecting “Home Address”:

Would you like your prescription sent to a different address from the one above?

• Yes
• No

If yes, please provide the new address and the reason for the change:

Current Pulse Rate (bmp)

Current Blood Pressure

Current Weight

Mood *

Describe your current mood

Energy Level *

Describe your current energy levels

Sleep Pattern *

Describe your current sleep patterns

Yes, please GP

Appetite *

Describe your current appetite levels

Any unusual thoughts, suicidal thoughts or experiences?

• Yes
• No

If you answered Yes, please describe

Medication Required & Dose *

How many days of medication do you have left *

Are you currently on a Shared Care Agreement and receiving medication directly from your GP

• Yes
• No

If you answered Yes, please provide details

Other Details

Submit

IMPORTANT NOTE

There is a standard fee of £45 for issuing a repeat prescription outside of a follow-up appointment. A payment link will be sent if your request is accepted.

This fee does not include the cost of the medication, which will need to be paid directly to the pharmacy.

Next Steps

• Your request will be reviewed by your consultant. If approved, a payment link will be sent to you.
• Please note that there is no guarantee your consultant will be able to issue a repeat prescription. They may require a follow-up appointment before proceeding. If so, we will provide you with available appointment options.