Repeat prescription form

Shortages of some ADHD medications

Please note

This form is for repeat prescriptions only. Do NOT complete this form if your local GP usually provides your medications.

We do not recommend the use of herbal/homeopathic products to support your child’s sleep as it may interfere with other medications your child is taking or have the potential to cause unwanted effects. Please speak with your doctor, nurse specialist or pharmacist for further information.

Check your spam folder

If you do not receive an email confirmation for your request, please resubmit or contact the team. Ensure the notification is not being delivered to your spam/junk folder before contacting us.

Please complete this form to request your child’s medication. Complete as much of the information as accurately as possible. A delay will be caused if we need to clarify this information. We aim to send out your prescription to your requested location within 3 weeks of making the request.

Please note we do not recommend the use of herbal/homeopathic products to support your child’s sleep as it may interfere with other medications your child is taking or have the potential to cause unwanted effects. Please speak with your doctor, nurse specialist or pharmacist for further information.

Is your child under the care of the Developmental Paediatrics/ADHD team?(Required)

Yes

Only medications managed by the Developmental Paediatric team can be ordered using this form. If you need to order other medications managed by other specialties, speak to your clinician’s PCO.

Do you have less than 3 weeks of medication left?(Required)

Yes

Unfortunately we will not be able to process your order if we receive it, please order when your child has 3 weeks of medication left.

Is there a possibility the person receiving this medication may be pregnant/breastfeeding?(Required)

Yes

Please contact your clinical team to discuss future prescriptions.

Contact ADHD/Community Paediatrics on 01512824930 or email [email protected]/[email protected]

Your child's name(Required)

First Last

Your Child's Hospital Number (AH Number)

Your child's date of birth(Required)

Birth Sex(Required)

Your name(Required)

First Last

Relationship to child(Required)

Address(Required)

Address Line 1 Address Line 2 ZIP / Postal Code

Mobile phone number(Required)

a text will be sent out once your prescription has been posted

Email address(Required)

Telephone number

Please select the medications your child is prescribed. If it is not listed, please select ‘other’ and specify what this is.

Medication Name 1 and Strength Required(Required)

Unfortunately, due to the national shortage of ADHD medications, this medication may not be available. It is important you do not take breaks from this medication. If we are unable to issue the prescription we will contact you

Unfortunately, due to the national shortage of ADHD medications, an alternative brand of this medication may be prescribed. This will be the same dose as your previous prescription and work in a similar way. If your child does experience any side effects this medication should be stopped, and the ADHD team should be contacted for advice. Please email [email protected] or call on 0151 282 4930.

Unfortunately, due to the national shortage of ADHD medications, an alternative medication may need to be prescribed if this medication is out of stock at the time of issuing this prescription. If this is the case we will contact you to discuss this.

Other medication 1 (please state here)(Required)

Number of tablets or mLs per dose for medication

How much and how often does your child take this medication i.e.1 tablet twice a day at breakfast and lunch. If there is no option that matches how you currently give medication please enter in the ‘additional information box’

Frequency (i.e. how many times per day)

Additional information relating to medication order

Add more medications

Add a second medication

Medication Name 2 and Strength Required(Required)

Other medication 2 (please state here)(Required)

Number of tablets or mLs per dose for medication 2

Frequency (i.e. how many times per day) for medication 2

Additional information relating to medication 2 order

Add more medications

Add a third medication

Medication Name 3 and Strength Required(Required)

Other medication 3 (please state here)(Required)

Number of tablets or mLs per dose for medication 3

Frequency (i.e. how many times per day) for medication 3

Additional information relating to medication 3 order

Add more medications

Add a fourth medication

Medication Name 4 and Strength Required(Required)

Other medication 4 (please state here)(Required)

Number of tablets or mLs per dose for medication 4

Frequency (i.e. how many times per day) for medication 4

Additional information relating to medication 4 order

Please nominate a pharmacy you would like your prescription to go to.

Please note, we are only able to deliver to pharmacies within the Southport, Sefton, Knowsley or Liverpool locality. Some online pharmacies are based outside of the area and we are unable to deliver to them.

Pharmacy name(Required)

Pharmacy address(Required)

Address Line 1 Address Line 2 City Post Code

Confirmation(Required)

I give my consent for my child’s prescription to be sent to the local pharmacy I have stated above. I confirm that the details I have provided are correct

All prescriptions will be hand delivered by courier to your local pharmacy.

We will send you a text once it has been delivered. Please ensure you have provided us with your up to date mobile number to enable us to do this.

Please note

If you do not receive an email confirmation for your request, please resubmit or contact the team. Ensure the notification is not being delivered to your spam folder before contacting us.

Repeat prescription form

Shortages of some ADHD medications

Please note

Check your spam folder