Nhs Repeat Dispensing Service Referral Form

NHS Repeat Dispensing Service

Referral Form

Date:

To (GP practice):

Re.

Patient:

DOB:

NHS number:

Address

We have been dispensing repeat prescriptions for the above patient for some time and note

that their medication regimen appears to be stable. This patient is suitable for the NHS

Repeat Dispensing service so we have explained the operation of this service to them.

I enclose a copy of their signed consent for the service / information sharing between your GP

practice and the pharmacy and would be grateful if you could consider use of the NHS Repeat

Dispensing service for future prescriptions.

Please do not hesitate to contact us should you have any queries.

Pharmacist

Pharmacy stamp

CONFIDENTIAL

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