Repeat Prescription Request

The easiest way to order repeat medication is via the NHS app.

Download from your app store – your ID is verified during the sign-up process and you will not need to attend the surgery.

Your list of available repeat medication will be shown which saves typing the names of your medication.

You can use your SystmOnline account if you already have one.

If you are unable to use the above methods you can use our repeat prescription form.

For items ‘on repeat’ please allow 5 working days and an extra day for the pharmacy to make up your prescription.  If you are requesting items which are not ‘on repeat’ please allow extra time as your doctor will need to authorise these.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

By giving us your email address on this online form, we assume consent to reply to this form via email when necessary. If you prefer not to receive email, please contact the surgery by telephone.

Do you have any communication/information needs relating to disability, impairment or sensory loss?

Yes

No

Please be specific:

Medication Required

Item Description

Strength

Quantity

1

Dose

Quantity

2

Item 2: Dose

Item 2: Quantity

3

Item 3: Dose

Item 3: Quantity

4

Item 4: Dose

Item 4: Quantity

5

Item 5: Dose

Item 5: Quantity

6

Item 6: Dose

Item6: Quantity

7

Item 7: Dose

Item 7: Quantity

8

Item 8: Dose

Item 8: Quantity

9

Item 9: Dose

Item 9:Quantity

10

Item 10:Dose

Item 10:Quantity

Additional Comments