Acute Medication Request Form

Last Updated: 19/10/2020

Acute Medication Request Form (This form should not be used to order repeat medication) - Please complete this form in full. Medication will not be prescribed if you have not discussed this treatment with a healthcare professional in the past 2 months. If this is your third request for this medication without seeing a healthcare professional your request will be DECLINED.

Medication Required -The following medication WILL NOT be prescribed without seeing a healthcare professional first for safety reasons. Co-Codamol, Tramadol, Codeine, Dihydrocodeine, MST, Oxycontin, Pain Patches, Zopiclone, Diazepam, Lorazepam, Temazepam, All Antidepressants, Naproxen, Ibuprofen, Diclofenac and All Antibiotics.