Prescription Requests

You can use this form to order any repeat or acute prescriptions from the surgery. Your prescription will be ready for collection within 48 hours (2 working days) of ordering.

Please note any other clinical requests will not be actioned through this form.

Your Details

Forename *

Surname *

Date of Birth *

Phone Number *

Prescription Collection Details

How would you like to collect your prescription? *

I wish to collect from the surgery.

My nominated pharmacy will collect from the surgery (please specify pharmacy below).

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

If a pharmacy is collecting, please state which pharmacy

Medication Details

Name of the medication you require? (Item 1 of 10) *

Name of the medication you require? (Item 2 of 10)

Name of the medication you require? (Item 3 of 10)

Name of the medication you require? (Item 4 of 10)

Name of the medication you require? (Item 5 of 10)

Name of the medication you require? (Item 6 of 10)

Name of the medication you require? (Item 7 of 10)

Name of the medication you require? (Item 8 of 10)

Name of the medication you require? (Item 9 of 10)

Name of the medication you require? (Item 10 of 10)

Name of further medications, if more than 10 items

Additional Comments (including if you are ordering your prescription early). Please note any other clinical requests will not be actioned through this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 07 August 2026
Page created: 27 October 2026

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Prescription Requests

Further Information