Travel medication

Address:

You can attach a copy of your Right Hand Side at the end of this form.

Please state which medication you require:

Start date of travel:

Please use this date format: DD/MM/YYYY

End date of travel:

Please use this date format: DD/MM/YYYY

Please state the time of your departure:

It is the patients’ responsibility to check if a letter for travelling is needed.

Do you require a letter for travelling?

Yes

No

Please note there is a £30 fee for this letter and can take up to 14 working days for it to be processed.

*

I have read and understand the Holiday Prescription Request Policy that is located on this page

Patient Signature: *

Date:

Please attach a copy of your Right Hand Side:

Maximum upload size: 67.11MB

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