INR Dosages

Please only complete this form if you have been asked to by a clinician at the Hollies Medical Practice.

INR Dosages

If you are human, leave this field blank.

Section

Date of last INR:

Result of last INR:

Present dosage:

Date of Next Test:

Would you like to order Warfarin?

Yes

Please select the way you'd like to order your Warfarin:

Through this form

Through Online Services

Please use our online services, Patient Access, to order your Warfarin.

If you are not registered for our online services, you can do so by submitting our Register for Online Services form.

Repeat or Acute:

Item Description:

Strength:

Quantity:

Are you currently due any other medications? Please list the name and dosage:

Declaration

Please confirm all of the following: *

I understand that I will be contacted within 48 working hours of my request being submitted to the Hollies Medical Practice (Excluding Bank Holidays).

I confirm the information I have submitted is correct to the best of my knowledge.

I understand that I must check any correspondence sent to my email from The Hollies Medical Practice..

Patient Signature: *

Date:

Tell us whether you accept cookies

Section

Declaration

NHS App