Your Details:

    Pharmacy Details:

    Medication Details:

    e.g.: Panadol


    3 times daily

    2 tabs

    1 month

    What do you want us to do with your prescription?*

    Please Note:

    • Please allow 48hours for request to be processed.

    • Patients may be asked to attend Dr for review depending on last attendance and current medications requiring monitoring.

    • I acknowledge that if I am collecting my script that this can only be done between 12.00-12.30 & 4.30-5.00 daily

    GDPR: We will only use the information you provide us in this form to deal specifically with your request for a repeat prescription and we will not use it for any other purpose.

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