Repeat Prescription Request Form

 Please let us know where you would like to collect your prescription from 



    Important Information

    Saving details help

    You do NOT have to register to order your repeat prescription - it is your choice.
    If you do not wish to register simply use the form below to place your order.

    There are some advantages to registering and you can read about them here. To register click the link above.

    Choose a Patient

    Patient Details

    Medication

    You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time.
    Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
    Drug Quantity and/or Strength
    e.g. 1mg once a day     		Required
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    Comments

    Please do not include medical problems here - these should be discussed with your doctor

    Sending Your Request





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    About This Form

    Fields marked with a red asterisk are
    compulsory.

    This form uses cookies to store your information for next time.

    The information is stored on your computer when you send your request or when you switch patients - but only if you check the 'Remember my details...' box.

    To save details for a second person use the radio buttons at the top of the form. To save details for more than two people or if you are having trouble with cookies, register with the prescription service and your details will be saved securely in the online database and recalled when you log in. Registering is quick, simple and free.

    Personal Information

    Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential. Where appropriate this data is deleted two months after its creation.

    By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of ordering a repeat prescription.