Your Details

First Name:

Last Name:

Your Phone Number:

Your Email:

Your Address:

Pharmacy Details

Name and Address of Preferred Pharmacy:

Medication Details:

e.g.: Panadol

500mg

3 times daily

2 tabs

1 month

1. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

2. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

3. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

4. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

5. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

6. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

7. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

8. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

9. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

10. Medication:

Dose:

How many times per day?:

Dose:

Quantity taken each day:

What do you want us to do with your prescription?

I would like you to send my script directly to my pharmacy

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 confirm that I have read the 2 previous points.

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.