Shropshire, Telford and Wrekin POD

Are you completing this form on behalf of:*

Patient First Name*

Patient Last Name*

Patient Date of Birth*

First line of Home Address*

Your First Name*

Your Last Name*

Relationship to Patient*

Contact Phone Number*

Contact Email Address*

About Your Request

Registered Practice*

Chosen Pharmacy Name*

Chosen Pharmacy Address*

Not sure where the closest pharmacy is? Use the NHS Find a Pharmacy tool.

Webform not in use

Additional Comments

You are not able to request any medications via the webform

The webform is no longer in use

Consent*

I am confirming that I understand that the webform is no longer in use and the request submitted will not be actioned by POD*

This webform is no longer in use – any webforms submitted will not be actioned.