Repeat Dispensing/Managed Repeats –
Patient Feedback Form
Patient Name
Date of Birth
Address
Post Code
Telephone Number
GP Practice Name
Practice Address
Pharmacy Name
Pharmacy Address
This form is to help us review and improve the Repeat (Batch) Dispensing Service- when repeat supplies are
managed by your pharmacy, and the Managed Repeat service-which is when the pharmacy orders your medication
for you, using your repeat medication list.
Question:
Please circle options for each question
Does the pharmacy ask which
Yes No
Always
Sometimes
Never
medication you need?
When does the pharmacy ask what
I was asked
Pharmacy
As I collected/
I always tick
medication you need?
when I
phones me
received my
the list ready
collected last
before it is
medication
for next time
time
due
this time
Has the pharmacy ordered or
supplied items that you have not
Yes No
Always
Sometimes
Never
asked for?
If yes to the above question, what
Delivery driver
They are removed Pharmacy asks you
happens to the items you didn’t
returns them to the from the bag in the
to keep them for
need?
pharmacy
pharmacy
next time
Have you highlighted this problem
Yes No
Doctors Surgery
Pharmacy
Delivery driver
to your pharmacy or your GP?
Do you have too much of some
Most of my
Some items of
Medication I no
items of medication because of this? Yes No
medication
medication
longer use
If so, please give examples below*
How do you obtain your medication
Delivered by
Collected by
Collected by you
from the pharmacy?
pharmacy
family/friend/carer
*Examples of extra medication received:
The Medicine Management team for Mid-Essex CCG and NHS England may want to contact you for further
information whilst reviewing this information. Please add your signature if you are happy for them to do so (or
practice signature if verbal agreement is confirmed over the phone).
Patient Signature (or practice
Date:
signature & role)