Care Home Staff

Interim medication request

Please do not use this form for monthly repeat prescription requests. Online services should be used for the ordering of monthly repeat prescriptions.

Other request

The Duty Doctor will review the request and provide a timely response appropriate to the urgency of the request.

Please do not use this form form for a medical emergency.

Registration for access to online services for care home staff (C1)

Patient consent for proxy access to online services for care home staff (C2)

Register a new resident as a patient with us (GMS1)

Register a temporary resident as a patient with us (GMS3)

Patient's details

Title
Date of birth
If you know your NHS number please help us by providing it
Gender
Home address
Temporary address
SMS text messaging service
Email
By providing your email address you are consenting to receive information from Springwood Surgery to your email address. Only consent to receiving emails if you do not share your email address/account with another adult and you regularly check your email inbox for new messages. You will receive an initial message requesting verification of your email account.
Address of doctor
I anticipate being a temporary resident for;

Medication

Springwood Surgery is enrolled within the NHS Electronic Repeat Dispensing System. If you are regularly taking medication and it is appropriate, your repeat prescriptions will be sent electronically to your preferred pharmacy.
Please nominate your preferred pharmacy to assist with the processing of any medication you may require now or in the future;

Signature

I am signing as;
Date