Repeat Prescriptions

Repeat Prescriptions

Please provide the following information:

*** = Mandatory Fields


Title: *******
Surname: *******
First Names: *******
Postal Address: *******
Your email address: *******
Date of Birth: *******

The following information can be found on your repeat slip.

	Drug Name	Strength
Request 1
Request 2
Request 3
Request 4
Request 5
Request 6

Any additional comments:

Please remember prescription request take 48 hours., and you may have to come in and see the doctor before more medication is issued. So make sure you order your medication in good time.

Do you want your prescription to go to one of the following for collection or will you collect from the surgery. Please tick.

Cooks	Boots (Replingham road)
Revelstoke pharmacy	I will collect it from the surgery

Click Submit Button to send: