Repeat Prescription Request

Please make your repeat medication request by completing the prescription request form below.

Please allow enough time for the surgery to process your request and for your pharmacy to prepare your medication.

Before you request your medication

Please order any repeat medication 7 days before it is due. This gives the surgery time to process your prescription and the pharmacy time to prepare and dispense it.
Wherever possible, we will send your prescription to your local designated pharmacy.
If you do not have a designated pharmacy and would like your prescription sent to one, please tell us your chosen pharmacy when you make your request.

Your Details

First Name

Surname

Date of Birth

For example, 15 3 1984

Day

Month

Year

Post Code

E-mail Address

Prescription Details

Preferred Collection Point

Medication Required

Please list all medications required to include Name, Strength / Dosage and quantity required. You can request up to 10 items using this form. Please list individual items below

Item 1 - Medication Name, Strength / Dosage, Quantity

Item 2 - Medication Name, Strength / Dosage, Quantity

Item 3 - Medication Name, Strength / Dosage, Quantity

Item 4 - Medication Name, Strength / Dosage, Quantity

Item 5 - Medication Name, Strength / Dosage, Quantity

Item 6 - Medication Name, Strength / Dosage, Quantity

Item 7 - Medication Name, Strength / Dosage, Quantity

Item 8 - Medication Name, Strength / Dosage, Quantity

Item 9 - Medication Name, Strength / Dosage, Quantity

Item 10 - Medication Name, Strength / Dosage, Quantity

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy. This information is not shared with any third party organisations. This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form

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