Prescription Request

IMPORTANT Please read our Privacy Statement regarding handling of the details that you submit via our website Click Here.

IMPORTANT You must fill out all fields marked with a * in order for your request to be processed.

When you have entered and checked all details on your prescription request please press the Submit button once only, if you wish to make changes press the Reset button and proceed to fill the form again.

To lessen any delays in processing your prescription please indicate which doctor you usually see regarding this condition or medication, so that the receptionist knows which doctor may be best able to check and sign your prescription.
To process your prescription request we also need your computer ID. Number printed at the top of your prescription:

1.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc

2.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc

3.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc
4.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc
5.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc
6.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc
7.Medication/Product Name (required)*
Form e,g, tablets, syrup, cream, appliance
Strength, Dose, Code etc

First Name*
Family Name*
Date of Birth*
Home Phone*

Please check that all the details entered above are correct before submitting this form, we will deal with your request in the normal Practice manner, your prescription will be ready for collection after 1.30pm, 48 hours after your request is received, provided your request is received by 11.30am. Only proceed if you have read and understood our Privacy Statement.