Medication Review

We review any regular medication on a repeat prescription annually and wherever possible the doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due please use this form.

Medication Review

Medication Review

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
If this is a mobile number we may send you information via text message. Please let us know if you would prefer us not to do this.
Are you completing this form on behalf of someone else? *

Your Medication

Do you understand why you take your medication?
Do you understand when you take your medication?
Do you understand how you take you medication?
Do you take you medications as directed by the label on the packet?
Do you have any concerns or side effects from your medication?
Do you think that any of you medication needs to be changed in any way?
Please wait for us to contact you to discuss this before taking any action.

Nominate a Pharmacy

Please nominate a pharmacy so that we can send electronic prescriptions directly to them. This saves printing costs and the risk of paper prescriptions getting mislaid.

Weight and Blood Pressure

If possible please you could provide an up to date weight and blood pressure reading so we can update our records.

Please provide blood pressure readings (ideally three):
Please use format Systolic “Higher” / Diastolic “Lower” / Heart Rate
Please use format Systolic “Higher” / Diastolic “Lower” / Heart Rate
Please use format Systolic “Higher” / Diastolic “Lower” / Heart Rate

Smoking Status

What is your Smoking Status:

If you would be interested in making some changes to improve your health through lifestyle, live well stay well can help.

They can support with increasing activity, improving diet, stopping smoking, improving mental wellbeing or reducing alcohol intake.

You can find out more at Be Healthy Bucks (

Once we have received this form it will be reviewed by our team. We will either update your medication review date, or be in touch if we need further information.