REPEAT PRESCRIPTION REQUEST

Please note that we can only routinely prescribe items on your repeat prescription slip. Items not on this slip will need to be sent to your usual doctor and may not be prescribed without an appointment. Please provide medication name, strength and dosage where known.

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We will not reply to this request unless there is a problem. Please allow 2 working days before you collect the authorised script.

Items in bold are required for successful receipt of your message.

PATIENT DETAILS
Patient Number (this can be found at the top of your prescription)

Email Address
Date of Birth
PRESCRIPTIONS REQUIRED
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
Other Medication (can be used to request a medication that you are occasionally prescribed but is not part of your regular prescription)

HOLIDAY INFORMATION
If you are going on holiday and require your prescription in advance please tick here and fill in the details below.
Destination outside the UK Yes No Length of Holiday [dd] Date of Departure [dd-mm-yyyy]
COLLECTION AND DELIVERY OPTIONS
I will collect the prescription from the surgery
I will collect the prescription from the pharmacy indicated below

Other Pharmacy
If you would like your chosen pharmacy to collect your prescription please contact them so they can pick up your prescription within 2 working days.
If you need to have your medication delivered, please discuss this with your pharmacy.
Please tick this box to confirm that you have completed your prescription request and click the 'Submit' button to send this request to the practice.