Repeat medication request form – The Quarter Jack Surgery

"*" indicates required fields

Name*

First Last

Date of birth*

Address*

Postcode*

Contact number*

Enter Email Confirm Email

Item description

Please use the (+) button at the end of the row to add as many rows as you need for your medications.

List*

Item 1 - eg Atenolol

Strength 1 - eg 50mg

Quantity 1 - eg 28 tabs

Pick up point*

Send prescription electronically to my usual nominated pharmacy

Send prescription to another pharmacy electronically as a one time request. Please add the pharmacy address in the notes box below

Additional notes

Please be aware the box below is ONLY for information relating your prescription request. Any other requests will not be actioned or responded to and you will need to contact us by submitting an online consultation form.

Not for urgent medical help*

Yes, I understand this form is NOT for urgent medical help