Online Prescriptions

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Please Note: This form is sent to us via computers that do not belong to the NHS in a non-encrypted format. Complete confidentiality for this type of repeat prescription request can not be guaranteed. If you have an issue with this please feel free to use our normal repeat prescription service OR you can register to order via Emis Access.

Please allow two working days before collecting your dispensed prescription.

Patients Name *
Date of Birth *
Patient Number* (as shown at the top of your repeat prescription form)
Daytime Contact Tel.*
Email Address
* You must provide this information. The items requested below MUST be on your regular repeat medication list. Patients wanting more than eight items should submit two forms.

Item Description

Dose

Quantity

(e.g. Paracetamol)

(e.g. 500mg)

(e.g. 100)

Item 1

Item 2

Item 3

Item 4

Item 5

Item 6

Item 7

Item 8

If you have to pay for your prescription, please make sure that you have cash or a cheque with you when you come to collect your medicines.

Comments about this Prescription

'NOT FOR MEDICAL PROBLEMS'