Prescriptions Form

Please note - All repeat prescriptions are regularly reviewed by your Doctor. This may mean that you will be asked to be seen before allowing your prescription to be processed.

On Line Prescription

The surgery will be closed on Public Bank Holidays.
Please allow at least 2 working days for prescription, more if there is a Bank Holiday
To order repeat prescription please fill out the following form.

Disclaimer: - Important Please Read

The form is not encrypted, but will be no less secure than a normal email. We cannot guarantee that the information will not be seen by others, but provisions have been taken to protect the data.

Required Information

If a form field has a * next to it, this is required information that must be supplied. The form will not submit if the required information is not entered.

PERSONAL INFORMATION Title
Other Title
Name *
Address *
Town *
County *
Postcode *
Telephone No.
Email address *

MEDICAL DETAILS

Your GP

Practice

CURRENT CERTIFICATION

... Do you have a valid Pre-payment certificate?

yes
no

... Do you have a valid maternity/medical exemption certificate?

yes
no

If you are unaware of the policy and require guidance about Prepayment of NHS prescription charges, please visit the Department of Health for assistance.

PRESCRIPTION REQUEST Prescription *
Strength *
Quantity *

Prescription
Strength
Quantity

...Please give any addition information which you think may be useful :

We recommend that when using this form you print off and keep a copy of the acceptance page (which pops up after the submit button has been pressed).

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