Complete the form below to request GP Discharge Letter

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

About you*

I am over 16 years of age

I am a parent/guardian of a person aged 12 to 15

Patient Details

First Name (Patient)*

Last Name (Patient)*

Date of Birth (Patient)*

Parent / Guardian Details

First Name (Parent/Guardian)*

Last Name (Parent/Guardian)*

Contact Details

Phone Number*

Email*

GP Details

Your GPs Name & Address*

Your GPs email address*

Medications, Blood Pressure, Heart Rate & Weight

Medication & Dose*

Please be as specific as possible as these will be the directions we will send to your GP. E.g. Concerta 36mg Monday to Friday, Concerta 27mg Saturday & Sunday.

Blood Pressure Systolic (mm Hg)*

Top number, i.e. 120

Blood Pressure Diastolic (mm Hg)*

Lower number, i.e. 80

Heart Rate (bmp)*

i.e. 80

Weight (kg)*

i.e. 70

Consent - Medication Dosage*

I confirm that I am happy to continue on my current dose of ADHD medication and I do not need to book an appointment to review this medication.

Consent - GP Discharge*

I would like you to send a letter to my GP so that they are up to date regarding my prescription / so that they can continue prescribing my ADHD medication.

Consent - Annual Review Contact*

I acknowledge that it is my responsibility to schedule an annual review appointment, as recommended by medical guidelines (nice.org.uk/guidance/qs39/chapter/quality-statement-7-annual-review-of-drug-treatment)

GP Discharge Midwest