Pharmacy Enquiry Form

Enquiries will only be answered between 9am and 5pm Monday to Friday and we aim to respond in 5 working days.If your query is urgent then please contact the hospital site pharmacy.
Please be aware that we are only able to answer questions relating to specific medication related queries and not clinical issues regarding diagnosis.

Please indicate the Hospital or site where the patient was treated and/or discharged from

Southend Basildon Broomfield

First Name:

Surname:

Job role:

Organisation/Place of work (and department where applicable):

How would you like to receive your reply?

Telephone number:

Email address:

Does your question relate to the following?

Outpatient prescription Discharge Prescription Another Medication issue

Does your question involve a specific patient?

Yes No

Patient identifiers not known

Patient's initials:

NHS number (if known):

Hospital number:

Date of birth:

Your question: Please provide as much information as possible to aid a timely response

When do you need an answer?

We will aim to respond within 5 working days, however if you have not received a response within this time period then please contact the hospital site pharmacy department.

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This form will send the personal information you have entered to us via email. This will be treated in the strictest confidence. We will use the personal information to respond to your enquiry. We will process your data in accordance with the Data Protection Act 1998.