Request a prescription - ADHD & Autism Clinic

Name(Required)

First Last

Date of birth(Required)

Mobile phone(Required)

Delivery address(Required)

Street Address City or county Post code

Who is your consultant?

Please list your order requirements(Required)

Medication name

Give dose (if different at different times of the day, please specify)

How many times a day?

How many days' supply do you need?

Please choose how you wish to receive your prescription/medication(Required)

Please note that prescriptions sent in the post will be sent by first class post and thus delivery date is not confirmed. CloudRx prescriptions are sent by Special Delivery but if a controlled drug prescription is required, CloudRx must wait for the handwritten controlled drug prescription before they may dispatch the medication. If you choose a prescription by SignatureRx, the e-token is available as soon as the medication is prescribed, but this service cannot be used for controlled drug prescriptions.

I wish to receive a paper prescription in the post

I wish to receive the medication in the post from CloudRx

I wish to receive an e-token from SignatureRx to take to my chosen pharmacy

General Data Protection Regulation (GDPR) Compliance(Required)

This form collects your name and email, together with the data contained in other fields on the form so that we can later communicate with you appropriately. Please check our PRIVACY POLICY for the all the information on how we store, protect and manage your submitted data. You must tick the consent box below before the form can be submitted.

YES, I AM OK WITH THIS, AND I HAVE READ, UNDERSTOOD AND AGREE WITH YOUR PRIVACY POLICY

Prescribing fee(Required)

Please note that this does not include the cost of your medication, which will be payable to your pharmacy provider.

Price:

Payment(Required)

MasterCard

Visa

Card number Expiry date CVV code (back of card) Cardholder name

Comments

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