Repeat Prescriptions Request Form - Church Street Surgery

Repeat Prescription Request

If you are not registered for online services, you can use this form to request any repeat prescriptions from the Practice. Please allow 2 working days before collecting your prescription. In future you may wish to consider registering for our Online Services. The Online Services system remembers which medications you are on and makes requesting repeat prescriptions faster and easier.

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Medication Required

What medication do you require? *

Additional Comments

Collection Details *

I have left a self-addressed envelope at reception and would like my prescription posted to me.

I have nominated a pharmacy and will arrange my collection from the pharmacy.

I wish to collect from the Practice

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 28 September 2020
Page created: 16 December 2024

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Repeat Prescription Request

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