Prescription Requests

*** PLEASE DO NOT SUBMIT URGENT MEDICATION REQUESTS OR MEDICAL QUERIES VIA THIS FORM - PLEASE CONTACT THE SURGERY ***

 

Please allow upto 5 working days before collecting your prescription. 

 

If you are not registered for online services, you can use this form to request your medication from the Practice.

Please note, prescription requests can be submitted in a number of ways including this form, paper, NHS app, Airmid app - ALL prescription requests are actioned in datal order.

In future you may wish to consider registering for our Online Services. The Online Services system remembers which medications you are on and makes requesting repeat prescriptions faster and easier.

Last Updated: 21/12/2023

  • Your Details

    DATE OF BIRTH
    For example, 15 3 1984
    Do you consent to the Surgery contacting you by text message?

  • Medication Required

    Please provide the following information for each medication required:

    Name of medication

    Strength of medication

    Quantity supplied

    How would you like to collect your prescription?
    This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
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