The Rycote Practice
Thame Health Centre
REPEAT PRESCRIPTIONS FOR HAYFEVER
The prescription for your hayfever treatment needs reviewing. It may be necessary to make
an appointment to see your doctor but you may feel happy with your treatment. If this is the
case please complete the answers to the following questions.
1.
Does the repeat prescription contain drugs OTHER than
Citirizine (Zirtek)
Loratidine
Fexofenadine (telfast)
Chlorpheniramine (Piriton)
Salbutamol inhaler (Ventolin)
Beclometasone nasal spray (Beconase)
Fluticasone nasal spray (Flixonase)
Sodium cromoglicate eye drops (opticrom)
Yes
No
Everything apart from salbutamol (Ventolin) and fexofenadine is available from the pharmacist without
the need for a prescription. Shop around for the best deal; they are usually much cheaper than the
prescription charge
2.
3.
4.
Have you lost any time from work/school due to
cough/wheeze or woken at night with cough/wheeze
in the last three months?
Yes
No
Do you want to see the doctor?
No
Yes
Are you expecting a baby or planning a pregnancy or breast-feeding?
Yes
No
If you have answered "yes" to any of the above questions you need to make an appointment with a
doctor. Otherwise, contact the reception team after two working days to make sure that your doctor
agrees that no appointment is needed.
NAME OF USUAL GP: ______________________________________
YOUR NAME: __________________________________
Date Of Birth: _______________
SIGNATURE: _____________________________________________
DATE: ___________________________________________________