REPEAT PRESCRIPTIONS

IMPORTANT

Please note that all requests for repeat prescriptions will be seen and verified by the doctor and therefore, only requests from patients entitled to receive repeat prescriptions will be accepted. If you are in any doubt as to whether this applies to you, please check with the Surgery before forwarding your details.

Name:(*)

Date of birth:   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1 2 3 4 5 6 7 8 9 10 11 12   2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 (*)

Address:(*)

Town: (*)

County: (*)

Telephone No:

E-mail address:

Surgery to which you are registered: Highworth Surgery Blunsdon Surgery

Please enter details of medication required, exactly as it appears on your repeat prescription order slip Medication that has not been added to your repeat slip cannot be ordered in this way. (*)

I would like to collect my prescription from: Please choose... The Surgery Newburgh Place Chemist Market Square Chemist (*)

 When you have filled all the required data on the form please submit it. If you make a mistake please reset and start again.

This submittal system uses standard e-mail to transfer your request to the surgery. The data is not sent through a secure channel and there is a very small possibility that it may be viewed by unknown third parties. This is beyond our control and we cannot bear responsibility for this.