Request Prescription
 

For patients who are registered with the Waiting Room service, please click here to log in.

For further information on the Waiting Room, please click here.

For patients who are not registered with the Waiting Room, please complete the request prescription form as indicated below.

This service allows you to request a repeat prescription. Please do not use this service to request medication you do not have listed on your repeat counter slip.

Please fill in all the grey boxes.
Use the TAB button on your keyboard, or use your mouse to the next box. Please do NOT hit Enter on your keyboard. If you do this, you will be told you have not filled in the form correctly and asked to do it again.
You must be a registered patient to use this service. If you are not registered, your request will be ignored. You can only request a prescription from the surgery whom you are registered with.
If you need to change your collection point, please do so on the 'Change Collection Point' page. This change will NOT be instant and your prescription will be sent to your usual collection point for this request.
You must accept the Terms & Conditions of this service by ticking the checkbox at the bottom of the form. You will not be able to use this form without accepting the Terms & Conditions of Service

 

Your Details

First Name*

Surname*
 

Date of Birth*



Phone Number

E-mail Address*

Your Doctor

 


Your Medication

Drug Name                                                  Drug Strength
  
 
 
 
 
 
 
 

Comments


Terms & Conditions

I accept the Terms & Conditions of Service*

 

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