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Prescription request
You can use this form to request any repeat prescriptions from the Practice.
** This is for requesting repeat prescriptions or previously prescribed medication
** Please allow 2 working days before collecting your prescription. If submitted after 2pm then this may be 3 working days
This will be sent to your nominated pharmacist automatically. If you do not have a nominated pharmacist please nominate one or the surgery will send to the nearest one to your current abode
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* Indicates required question
CONTRACEPTIVE PILL: If the request is about your contraceptive pill please use other form for safety reasons we require further questions therefore your pill request. Request using this form for the pill will not be processed
For the contraceptive pill:
https://forms.gle/JYo6znQb4FKzEJTc6
YOUR DETAILS
Please include your latest personal details so that we can contact you if necessary
Your Full Name
*
Your answer
Your Date of Birth
*
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
MM
/
DD
/
YYYY
Your MOBILE number
*
If we need to contact you to clarify your answers
Your answer
Your EMAIL address
*
If we need to contact you to clarify your answers
Your answer
PRESCRIPTION: Medication Required
Please provide detail of the name of the medication, strength and quantity
*
Please press enter between medication entries. i.e. paracetamol 500mg 1 tablets 4 times a day. 100 tablets.
Your answer
Please provide reason for the medication request. If NOT on repeat prescription please click OTHER and provide reason for taking this medication
*
i.e. Paracetamol for back pain
Repeat prescription
New medication issued by hospital
Other:
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