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Medication synchronisation request

Prescription Synchronisation Form

Phone
This field is for validation purposes and should be left unchanged.
If you would like to save time and order all the medication you have on repeat at the same time rather than irregular times throughout the month please use the form below. When you next need to request an item on repeat count up all the tablets you have and fill in the form. Your doctor will issue a “one off” prescription of the tablets you need to synchronise all your medication to within a day or two.
Name(Required)
First Last
Date of Birth(Required)
Day
Month
Year
Phone Number(Required)
Email Address(Required)
Name of your GP?(Required)
What Pharmacy do you collect your prescription from?(Required)
How many prescriptions do you need to synchronise and what are they for?(Required)
What happens to my information?
Personal and medical information about patients registered at Peverell Park Surgery is primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you (please refer to our Privacy Policy), for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
Consent(Required)
- I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

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Peverell Park Surgery & University Medical Centre

Medication synchronisation request

Prescription Synchronisation Form

What happens to my information?

Check out our CQC report