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Medicines advice for patients form

Patients of North West London Hospitals NHS Trust may use this form to ask our pharmacists about their medicines; for other enquiries contact NHS Direct on 0845 46 47 (www.nhsdirect.nhs.uk). To make a general comment about the Trust, you can use the main feedback form.
During the working week we aim to reply to enquiries within 24 hours. In most instances we will reply by phoning you during the day; in addition we may contact you by email.

Your forename:

Your surname:

Your telephone number:

Your email address:

Preferred method of contact:

Who does this enquiry relate to?

Date of birth:

What is their Date of birth?

What is their Date of birth?

What is their Date of birth?

Sex :

What is the sex of the patient you are enquiring about?

Are you pregnant or breastfeeding?

Is the patient pregnant or breastfeeding?

Is the patient pregnant or breastfeeding?

How many weeks pregnant are you?

How many weeks pregnant is the patient?

Does the patient know you are contacting us on their behalf?

Does the patient know you are contacting us on their behalf?

Does the patient know you are contacting us on their behalf?

What is your hospital number (if available):

What is their hospital number (if available):

What is their hospital number (if available):

What is their hospital number (if available):

Please give details of any medication you are taking, including any herbal remedies and over-the-counter pharmacy products. Please give details of the strengths and doses used (eg, aspirin 75mg each morning):

Please give details of any medication the patient is taking, including any herbal remedies and over-the-counter pharmacy products. Please give details of the strengths and doses used (eg, aspirin 75mg each morning):

Please give details of any medication the patient is taking, including any herbal remedies and over-the-counter pharmacy products. Please give details of the strengths and doses used (eg, aspirin 75mg each morning):

Please give details of any medication the patient is taking, including any herbal remedies and over-the-counter pharmacy products. Please give details of the strengths and doses used (eg, aspirin 75mg each morning):

Please give brief details of any conditions you have or have had in the past (eg, High blood pressure, diabetes):

Please give brief details of any conditions the patient has or has had in the past (eg, High blood pressure, diabetes):

Please give brief details of any conditions the patient has or has had in the past (eg, High blood pressure, diabetes):

Please give brief details of any conditions the patient has or has had in the past (eg, High blood pressure, diabetes):

Please type your question below:

This form will send the personal information you have entered to us via email. Whilst this will be treated in the strictest confidence we cannot guarantee the security of global internet/email systems. You may wish to read the Trust’s internet privacy statement. If you prefer we can provide medicines advice by telephone on 020 8869 2762 (Monday to Friday, 9am to 5pm).