Shropshire, Telford and Wrekin POD

NHS Shropshire, Telford and Wrekin Prescription Ordering Direct (POD) Request

Are you aware that you can use the NHS app to order your repeat medications? You can download the NHS App to your smart phone via Apple App Store or Google play store for Android. For more information please visit the NHS App website: https://www.nhs.uk/nhs-app/

Are you completing this form on behalf of:*
- Yourself
- Someone else (e.g. a child or dependent)
Patient First Name*
Patient Last Name*
Patient Date of Birth*
DD slash MM slash YYYY
First line of Home Address*
Your First Name*
Your Last Name*
Relationship to Patient*
Contact Phone Number*
Contact Email Address*
About Your Request
Registered Practice*
Chosen Pharmacy Name*
Chosen Pharmacy Address*
Not sure where the closest pharmacy is? Use the NHS Find a Pharmacy tool.
Repeat Medication Required
If the strength or quantity field listed below is not applicable, please specify using ‘N/A’. If you are ordering your medication and you have more than 7 days supply left, please explain why you are requesting your medication early in the additional comments box.
Additional Comments
Repeat Medication Required*
Item Description Strength Quantity

This service is for repeat medication only. Requests cannot be processed for urgent prescriptions.
Consent
Consent*
I consent to the NHS POD service accessing my full medical record in order to process my repeat prescription.*
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Item Description	Strength	Quantity

NHS Shropshire, Telford and Wrekin Prescription Ordering Direct (POD) Request

About Your Request

Repeat Medication Required

Consent