Medication Request

For repeat prescriptions please click here. If you need a new prescription please continue.

 

If you need prescribed medication the doctor will contact you for an online consultation in the next 48 hours. If approved the Doctor will issue your prescription to the Park Pharmacy and send the medication to your home.

 

Fees for prescription and online consultation is £50, this does not include the cost of your medication, but includes postage.

 

Please fill in the form bellow and you will be contacted in 48 hours.

 

As with all medications, you can have a side effect from it and may need a alternative.

 

This questionnaire needs to be answered completely and honestly in order to identify any problems. Your confidentiality is of utmost importance to us and we are fully compliant with the Data Protection Act 1988.

 

 

 

Required

Required

Required

Required

Required

Required

Submitting Form...

The server encountered an error.

Form received.

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

You do not have to provide your doctor's details and your doctor will only be contacted with you prior consent.

Please state none if none.

Please state none if none.

Please state none if none.

Please state none if none.

Please state none if none.

Have you ever had or been diagnosed with any of the bellow?

Your answers to this questionnaire will be reviewed by a qualified medical doctor. If any concerns arise you may be contacted and/or the prescription may not be dispensed unless further information is obtained.

 

This service is no substitute for a face-to-face assessment by a qualified medical professional, we always advise you to do this. We provide this service if necessary. If you have any concerns or queries please contact us or any qualified medical professional immediately.

 

By signing this waiver, I agree, to release liability and hold blameless The Park Clinic London and Park Pharmacy including all of their affiliates, directors, officers, employees, agents, doctors, and pharmacists from all causes of action, suits,

penalties, liens, and judgments liabilities, obligations, losses, actual or consequential damages, actual or threatened claims which may arise at any time by reason of relating to, arising directly or indirectly out of any matter whatsoever related to the prescribing or dispensing of my prescription medications.

 

I further agree that should I become aware of any changes in my physical and mental conditions, I will notify The Park Clinic London and Park Pharmacy of such changes, and agree that I am solely responsible for any adverse effects from continuing taking these prescribed medications. I understand and acknowledge that medical diagnosis, opinions and treatments differ among doctors, and that there is no warranty that treatments may be beneficial to me. I further state that all questions I have about my prescription medications, including prescription drug interactions and their risks and complications have been answered.

 

I also state that I have had physical examinations by the doctor within the last twelve months. I understand that is it is my responsibility to have regular physical examinations by my country’s licensed doctor to ensure I have no medical problems which would constitute a contradiction to me taking the medications being prescribed for me.

 

I also agree that should I suffer any adverse effects while taking these prescribed medications that I will immediately contact my licensed doctor whose care I am under. Should I come under the care of another doctor, I will inform him or her of any and all medications I am taking which have been prescribed.

 

I hereby give my consent to The Park Clinic London services doctors to review my medical questionnaire to determine if the medications I am currently prescribed by my Park Clinic London Doctor are appropriate. If necessary, you may contact my doctor for more information for the purpose of filling my prescription.

 

I understand that any information provided may be seen by the corporation’s employees and that said information will constitute a confidential medical record. I hereby consent to the use of said records for the purposes of filling any and all prescriptions.

 

I acknowledge that the doctors and pharmacists contracted by The Park Clinic London and Park Pharmacy  are located and licensed to practice medicine and pharmacy in the United Kingdom. I further understand and acknowledge that the services rendered of said pharmacists and physicians will be provided in and from the United Kingdom.

 

The Park Clinic London reserves the right to change this Disclaimer and medical consultation form at any time. I agree to read the Patient Disclaimer form every time I place a new order and understand that I must complete a new Patient Disclaimer form once every 12 months.

 

I hereby state that I am at least 18 years old and am fully competent to make my own health care decisions. I understand that it would be a violation of the law to falsify information on my medical questionnaire for the purpose of obtaining prescription medication. I agree to truthfully and to the best of my knowledge answer all the questions on the questionnaire.

If you have a prescription please send a photo or a scanned copy to prescriptions@parkcliniclondon.co.uk with your name and date of birth after submitting this form.

This website is updated every week!

© The Park Clinic London, Ltd.2017

Full wheelchair access available