ADHD: Right to Choose Information

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Prescription Alignment Form

Please complete the prescription alignment form below, this will be sent to our Pharmacist. Prescription Alignment FormHelping to align prescription ordering for patientsPlease enable JavaScript in your browser to complete this form.Name *FirstLastLayoutDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number *Email *EmailConfirm EmailPlease select the appropriate number of repeat medications you need to order: 1 – 4 5

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Easy Read

The Easyhealth website was made so that people know where to find ‘accessible’ health information. ‘Accessible’ information is information that uses easy words with pictures. Link to Easyhealth information: http://www.easyhealth.org.uk/ Below are links to just some of the leaflets available on the Easyhealth site. Cold & Flu Information: http://www.easyhealth.org.uk/listing/colds-and-flu-(leaflets) Complaining: http://www.easyhealth.org.uk/listing/complaining-(leaflets) Confidentiality: http://www.easyhealth.org.uk/listing/confidentiality-(leaflets) Consent: http://www.easyhealth.org.uk/listing/consent-(leaflets)

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