Please Note: This form is sent to us via computers that do not belong to the NHS in a non-encrypted format. 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.
Patients Name *
Date of Birth *
Address
Contact Tel.*
Usual doctor	Select your usual doctor Dr Roger Chapman Dr John Henderson Dr Mary Horkan Dr Rosalyn Lucy Dr Nasir Jamal Dr Claire Stewart
* You must provide this information. The items requested below MUST be on your regular repeat medication list.
	Item Description	Dose
	(e.g. Paracetamol)	(e.g. 500mg)
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
	* Please type the red word in lower case into the box below (in order to help us reduce spam email)

2 full working days will be required for processing this request.
Requests are reviewed daily during opening hours.