Request a Repeat Prescription Online

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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. We aim to make your prescription available within 48 hours of your request. Please note that if you have requested medication which needs to be re-authorised (your repeat medication slip will make this clear), you need to make a face-to-face or telephone appointment with a doctor.
Patients Name *
Date of Birth *
Address
Contact Tel.*
Email Address
Collection*
* You must provide this information. The items requested below MUST be on your regular repeat medication list.
	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
	* Not for medical problems *
Comments about this Prescription