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Query my Pharmacy Medication?

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Pharmacy Medication Query

Required fields are marked with an asterisk (*).

Date

**PLEASE NOTE – This is a query form for Pharmacist use ONLY. If completed by a Patient, this form will not be processed**

Patients MUST contact POD (Prescription Ordering Direct) on 01952 580 350 (8am-5pm) or email them at tw.pod@nhs.net (8am-5pm). Please be advised that POD is not part of Shifnal & Priorslee Medical Practice.

Pharmacy Name*

Pharmacy Email address for response*

Pharmacy Contact Name*

Telephone number*

Please complete the patient details below

Patient's Name*

Date of Birth*

NHS No.*

Medication Name*

How can we assist you?*

*Please make sure all Mandatory fields have been completed

*Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data *

I consent to the practice collecting and storing my data from this form

Are you human?*

This field should be left blank