Repeat Prescription Form

Please remember, we still need two working days to process your prescription request. In line with general practice policy, we cannot take repeat prescription requests over the telephone as the margin for error is huge !

For whom are we preparing this repeat prescription ?

Please let us know who you are ...

Name ?
Date of Birth ?

What is your address please ?

If we need to contact you about this prescription request, how can we

contact you ?

Daytime telephone number                  

Evening / weekend telephone number  

Medication details...

Name of medication ?   

 (this will be on the packet)

Dose ? e.g  mg or  mcg

How much do you take each time ? 

e.g. two capsules, one tablet etc

How often a day do you use this ?

e.g twice a day, apply once daily etc

What quantity do you require ? 

e.g. 28 tablets or 1 month, 2 months etc    

What would you like us to do with your prescription when completed ? Click on one of the two options.

Keep it at the surgery for you to collect from the front desk Post it to your home address

Please press the submit button now if you wish to send your request to the surgery.