What the Patient Needs to Know

I (the patient) understand that:

  • My prescriber will give me an "authorising" repeat dispensing prescription (the form with "RA" printed on it) and a number of repeat dispensing issue forms (forms with "RD" printed on them). The authorising prescription is valid for up to one year.
  • I need to take the "authorising" repeat dispensing prescription and the first repeat dispensing issue form to the pharmacy where I will get my medicines or other items.
  • The pharmacy will keep the "authorising" repeat dispensing prescription and first repeat dispensing issue form when they give me my medicine or other items. I will look after the other repeat dispensing issue forms or ask the pharmacy to do this for me.
  • I shouldn't sign all the forms in one go. I should complete Part 1 or Part 2 and sign in Part 3 on the reverse of the form when I collect a repeat from the pharmacy (or get my representative to do this for me).
  • If I pay prescription charges I understand I must pay a prescription charge (or charges) each time the prescription is repeated.
  • I should return to the pharmacy whenever I need more medicines or other items until all the repeat dispensing forms are used up. When this happens, I understand that I will need to go back to my prescriber to get another set of repeat dispensing forms (he or she may check first that I will need my medicines or other items).
  • I have to use the same. pharmacy for my repeat dispensing. If I want to change to another pharmacy I understand that I will need to get a new set of repeat dispensing forms from my prescriber to take to the new pharmacy.
  • My pharmacist does not have to give me every item listed on the repeat dispensing issue form (for instance, if I have plenty of medicine left at home).
  • I should let my pharmacist know about other medicines I am taking, so he/she can check it is safe to take these with my repeat dispensed medicine. I should tell my pharmacist about any other medicines I am taking:
  • after a hospital or dental appointment etc.
  • from another pharmacy (including non-prescription items such as coughlcold remedies); or
  • herbal or other" alternative" medicines.
  • I should tell my pharmacist if I stop taking my medicines for any reason.

Patient Agreement to Sharing Information (as part of the Repeat Dispensing Arrangements)

Patient name:

and address :

Patients chosen pharmacy - please tick one box:

Applebys, Durrington / Moss, No 20, Amesbury / Rowlands, Pembroke Road
Boots, Silver St / Moss, No 40, Amesbury / Rowlands, St Ann St
Co-op, Winchester St / Moss, Estcourt Road / Rowlands, Harcourt
Downton Pharmacy / Moss, Tisbury / Superdrug, Old George Mall
Lloyds, Market Place / The Pharmacy, Mere / Tanday, Wilton Road
Lloyds, Wilton / Rowlands, Castle St / Tesco, Bourne Centre
Other (please supply pharmacy name and address)

I am the patient named above. My prescriber or a member of the practice staff has explained repeat dispensing to me. I have also been given a leaflet about this.

I have read "what the patient needs to know" overleaf and I understand what I have to do.

I agree to the exchange of information about my medication or treatment between my

prescriber and my Pharmacist as part of the repeat dispensing arrangements.

Patient's Signature: Date:

Date of Birth:

Patient's Telephone Number:

Prescriber's name and telephone number:

Signature of Prescriber/Member of Practice Staff: