As a Prescription Question Prescription Questions Who are you completing this form for? Yourself Someone else for example, on behalf of a child or dependentName First Last Date of Birth DD slash MM slash YYYY What is your sex? Male Female Other As recorded on your medical recordWhat is your postcode?The one used to register with your GPWhat is your phone number?What is your email address? Anyone else with access to your email account may see responses sent to youNamed GP (if known) OptionalWhat is your prescription question?Consent I confirm that my enquiry is not urgent, and it may take up to 3 working days before I receive a reply. Optional