Repeat Prescription Request Form

Repeat Prescription Request Form

* = Required field

First Names:

Last Name:

Date of Birth (dd/mm/yyyy):

Email Address:

Phone Number:

Please tell us the drugs you require. Be specific and check your spelling. Please take all details from your repeat prescription record slip.

Drug Name	Strength
*

If you require more than 10 items, please submit another request.

Comments:
(any comments that you may have about this service, or additional medication)

CONFIDENTIALITY - TERMS AND CONDITIONS:
The internet is not secure, and the transmission of data to request medication is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above*

Pharmacist

South Lewisham

Repeat Prescription Request Form