ADHD Medication Repeat Prescription Request

Prescription request form for existing clients

If you are happy with your current medication and dosage, you can request a repeat prescription using the form below. If you have any concerns, are experiencing side effects, or feel your medication or dosage needs to be reviewed, please contact us before submitting your request.

Your details

Please ensure all information provided in this form belongs to the client, as incorrect details may delay processing

Full Name *

Date of birth *

Email address *

Phone number *

Consultant name

Health & Wellbeing Check These details help your consultant review the request safely.

Pulse rate

Blood pressure

Weight

Mood

Energy

Sleep

Appetite

Any side effects?
NoYes

Any unusual thoughts, suicidal thoughts or experiences?*
NoYes

Additional wellbeing notes

Medication Details Tell us about the medication you need repeated.

Medication name *

Dose & strength *

Days remaining *

Do you have a Shared Care Agreement?
YesNoNot sure

Additional InformationAdd anything else your consultant should know.

Message

Your information is secure and will only be used to process your request.

Important information

Please allow at least one week for
your prescription to be processed.
Your request will be reviewed by our team.
Approval is not guaranteed. You may be asked to book a follow-up appointment.
Medication cost is paid separately to the pharmacy.

Prescription Fee

£80

Only payable if your request is accepted. This is separate from pharmacy medication costs.

Need help?

Our support team can help if you have a question before submitting your request.

0203 966 1551
connect@adhdcentre.co.uk
Mon - Fri 8:30AM - 5PM

Health & Wellbeing Check These details help your consultant review the request safely.

Medication Details Tell us about the medication you need repeated.

Additional InformationAdd anything else your consultant should know.

Main Information

Our Expertise

Our Centre Address

Marylebone

Belgravia

Manchester Clinic

Postal Address

Health & Wellbeing Check These details help your consultant review the request safely.

Medication Details Tell us about the medication you need repeated.

Additional InformationAdd anything else your consultant should know.

Main Information

Our Expertise

Our Centre Address

Marylebone

Belgravia

Manchester Clinic

Postal Address

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