Repeat Prescriptions

Please Note: This form is not secure. The information sent by using this form is not encrypted and is no more secure than normal email. Complete confidentiality for this type of repeat prescription request can not be guaranteed. If you have an issue with this please feel free to use our normal repeat prescription service or sign up for Emis online services by contacting reception. We aim to make your prescription available within 48 hours of your request. Please note that if you have requested medication which needs to be re-authorised (your repeat medication slip will make this clear), you need to make a face-to-face or telephone appointment with a doctor. If you request collection method as post you must have previously provided the surgery with stamped addressed envelopes (we are happy to hold up to 12 for you).
Patients Name *
Date of Birth *
Address
Contact Tel.*
Email Address
Collection
* You must provide this information. The items requested below MUST be on your regular repeat medication list.

	Item Description	Dose	Quantity
	(e.g. Paracetamol)	(e.g. 500mg)	(e.g. 100)

Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8

	* Please type in the green word above in lower case into the box below (in order to help us reduce spam email)
	Not for medical problems
Comments about this Prescription