Medication Query Form Name First Last Date of Birth DD slash MM slash YYYY What is your postcode?The one used to register with your GPWhat is your phone number?What is your email addres? Anyone else with access to your email account may see responses sent to you Medication QuestionsAre you requesting a prescription exemption and for what reason? Yes No See list of exemptions Is there a problem with one or more of your medications? Yes Optional No Optional Is your query regarding a new medication which has been started by healthcare professional outside of the practice, for example by a hospital specialist? Yes No Please provide information about the issue and how you would like us to help: OptionalList the names of the medications(s) you have a query or request concerningName of medicationStrength Add RemoveConfirmation I confirm that my enquiry is not urgent, and it may take up to 2 working days before I receive a reply.