REPEAT PRESCRIPTION REQUEST FORM

Please allow a minimum of two working days (48 hours) between the request and collection.

From time to time we will ask you to see the doctor or specialist nurse to review your treatment and update your repeat prescription.

Please note -

1) This is not a confidential service, the system uses email and is not encrypted. Patients use this system at their own risk.

2) You are not able to save repeat prescription requests online due to the Data Protection Act.

If you experience any problems with this form please let us know.

* = Indicates required information.

REPEAT PRESCRIPTION REQUEST Title: Please Choose... Mr Mrs Miss Ms Other *First Names: *Last Name: *Date of Birth (dd/mm/yyyy): *Email Address: *Daytime Phone Number: *First Line of Address: *Please Select The Surgery You Are Registered At: Brookside Surgery Chalfont Surgery Winnersh Surgery Please tell us the drugs you require. Please be specific and check your spelling. Please take all details from your repeat prescription record slip. Failure to complete details correctly can result in delay of your prescription. Drug Name Strength Quantity If you require more than 10 items, please submit another request. CONFIDENTIALITY - TERMS AND CONDITIONS: The internet is not secure, and the transmission of data to request medication is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. Please Note:- You can only ask for items on your current re-order form. If we can not identify an item as being on your repeat prescription form, or if your repeats have expired, we will not be able to process the prescription. The prescription will be ready for collection in 2 working days at the surgery you select. You must arrange the collection. We cannot enter into correspondence via email. I accept the terms and conditions above

An automatic reply will be sent to confirm your repeat prescription request.