Medication Review Form

Please do not complete this form if: 

  • You are prescribed more than 6 items on your repeat prescription. 
  • You have been asked by the practice to submit a blood pressure reading. 
  • You have been asked to have your bloods taken. 

All Asthma, COPD, Diabetic and DOAC patients will require a face to face annual review with a clinician. 

Last Updated: 25/01/2024

  • Contact Details

    Date of Birth
    For example, 15 3 1984

  • Current Medication

    Are you able to take your medication as prescribed every day?
    Do you understand how and when to take your medication?
    Do you take any medication which is not currently prescribed by Waterfront Medical Centre? This includes any herbal medication i.e. St Johns Wart
    Do you understand why you are taking the medications prescribed to you?

  • Effectiveness

    Do you feel like your medication is effective?
    Do you suffer any side-effects from any of your prescribed medication?

  • Further Information

    Do you smoke?
    How much alcohol do you drink?

  • Outcome

    • You will be advised within two weeks if your medication review has been successful.
    • The practice will pre-book you an appointment via phonecall or text if you are required to discuss the management of your medication with the practice pharmacist. 

  • Consent

    This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow Waterfront Medical Centre to contact you, and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form.
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