Date of Birth:
Name of your Consultant:
Would you like your prescription sending to a different address?:*YesNo
If yes, please add the address below and the reason for sending to this address:
Current Pulse Rate(bmp):*
Current Blood Pressure:/
Mood, please describe your current mood*
Energy: please describe your current energy levels:*
Sleep: please describe your current sleep patterns*
Appetite: please describe your current appetite levels*
Any unusual thoughts, suicidal thoughts or experiences?*YesNo
If you answered Yes, please describe*
Medication Required & Dose*
How many days of medication do you have left*
Prescription delivery: Would you like your prescription sending:*Via Royal Mail Special DeliveryVia Delivery Pharmacy
Anything else you wish to add?
What happens next Your request will now be passed to your consultant. If they are able to send a repeat prescription we will then send you a payment link for this. PLEASE NOTE – there is no guarantee your consultant will be able to issue a repeat prescription and they may need to see you for a follow-up appointment before being able to do so. If this is the case we will come back to you with options for appointments.
We are a team of experienced Consultant Psychiatrists, Psychologists and ADHD Behavioural Coaches.
We have been diagnosing and treating people with ADHD since 2009.
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