Tees Online Doctor
Private Prescription Template
Service

Tees Online Doctor

Contact
Prescription Ref.
Patient Details

Full name

Date of birth

Address

Postcode

Prescription Details

Date issued

Issue type

GP informed

Prescription ID

Review date

SCR checked

Medication Prescribed
Medicine Strength Form Qty Directions
Clinical Notes / Safety Information (Cautionary advice)
Prescriber Details

Prescriber name

Professional registration no.

Electronic / wet signature

Date

Important: This is a private prescription template for use following an online clinical assessment. Medication should only be issued when clinically appropriate. If the patient develops severe side effects or urgent symptoms, they should seek emergency medical attention.