Queenstown Road Medical Practice

© 2005; Queenstown Road Mecidal Practice. Please see our disclaimer ....

REPEAT PRESCRIPTION FORM

Surname...........

Forename.........

Date of Birth.....

Phone Number.

Address...........

 

Item 1 Strength Frequency

Item 2 Strength Frequency

Item 3 Strength Frequency

Item 4 Strength Frequency

Item 5 Strength Frequency

Additional Information

 

Repeat prescription requests cannot be accepted by email. This is the only online method of requesting repeat prescriptions. Please allow 2 working days for your prescription request to be prepared. Please collect your prescription from your usual delivery location. Unfortunately we are unable to post prescriptions to you unless a S.A.E has been submitted.

Please use this form only for medications you have been prescribed regularly. Do not use it for antibiotics or medicines you have been prescribed only by the hospital.

This form will not be processed if you have not entered your personal details in full.

 

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