Repeat Prescription Form for ADHD Medication

This form is for patients who have completed commencement and titration of ADHD medication with Midlands ADHD Clinic or Malvern Hills Private Practice.

You are welcome to order all repeat prescriptions via this form. Please note, the type and dose must match your previous prescription. For a prescription change please call 01684 647 500 to book a review consultation.

Midlands ADHD Clinic. Repeat Prescription Ordering Form

Patient Information

Todays date:

Patient's First Name (as registered with us)

Patient's Surname (as registered with us)

Patient's Email (as registered with us)

Please give the same email address that you gave when registering with our system originally.

Patient's Date of Birth (dd.mm.yyyy)

Medication Information

What is the name of the Prescriber you most recently met with?

Bolu Abifarin

Ashiyana Vali

Adil Bhaloda

Kirsty Inglis

What repeat medication would you like prescribed (type and dose)? This must be a repeat and match what we have on file.

If you wish to change your prescription please telephone 01684 647 500 to book a review consultation.

Delivery Information

Dispensing Pharmacy
Your medication will be ordered from Cloud RX. Due to regulations we can only provide one months supply.

Fee
There is a fee of £30 to order a prescription with our service (+£10 optional faster delivery of script to pharmacy).

Delivery Time
Due to current legislation, your paper prescription has to be posted to the pharmacy prior to any medication being released. This means delivery time frames are approximately 8 working days from ordering through to receiving medication.

I confirm I have read the above

Payment Information

We charge £30 for a repeat prescription. This will be taken from the card attached to your account. We will text you if payment is declined or your card details are not stored.

I give permission to take £30 from the stored card

The pharmacy requires us to post your paper prescription using Royal Mail. The above includes first class postage. However Royal Mail time frames can vary greatly from 2 - 6 days. We recommend faster tracked delivery is added to your fee.

I give permission to take £10 for faster delivery of prescription to Cloud RX

Expectations of Time Frame

Please confirm:

I understand that I may need to wait 7-8 working days to receive my medication to do turnaround and posting times.

If I am concerned about a delay, I will initially contact Cloud RX on pharmacy@cloudrx.co.uk for an update

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