GP Websites - Repeat Prescription Form

Practice Name/Logo

You can change the following text to your own requirements as required.

Please note that we do NOT accept Repeat Prescription requests by email, any received will be ignored. This online form is the ONLY accepted method for receiving online Repeat Presciptions.

All the information you need to complete this online form can be found on the paper Repeat Prescription form issued to you by your Doctor. It is important that we receive a fully completed online form containing the correct data otherwise a Repeat Prescription cannot be issued.

We can only accept Repeat Prescription requests for items listed on your paper Repeat Prescription form, unauthorised items cannot be dispensed.

Repeat Prescription Form

Patient Name:
Address:
Date Of Birth:
Home Telephone:
Email Address:

	Item Description	Dose	Strength
Item 1:
Item 2:
Item 3:
Item 4:
Item 5:
Item 6:
Item 7:
Item 8:
Item 9:

Additional Information:

Please allow two working days for your prescription to be prepared.
Collect your prescription from your usual delivery location.