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Prescriptions - online request

Your full name
Your surgery reference number You can find this on your repeat prescription
I would like to collect this prescription from

The information you are submitting will be encrypted and then held in our website database until we have processed your request, when we will then delete the information. Please tick here to say that you understand and agree to this   

  Name of
Item		 Strength of medication How many
required
     
Example		   
Aspirin tablets		      
75 mg		       
28
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10

Please send me a receipt !  (Optional)


If you would like a receipt then enter your email address here - we will send a receipt listing the items requested. Security warning: Please remember that if other people have access to this email address then they may read the contents of the email.