Repeat Prescription Request Form

56-60 Grange Road, West Kirby, Wirral, CH48 4EG (Tel: 0151 625 5700)

From 1st April 2019, we will be at Hoylake and Meols Medical Centre

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Repeat Prescription Request Form

Important Information

You do NOT have to register to order your repeat prescription - it is your choice. If you do not wish to register simply use the form below to place your order.

Patient Details

Full Name:

Date of Birth:

Email:

Confirm Email:

Day Time Tel:

Your Doctor:

Collect From:

Medication

Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
	Drug	Quantity and/or Strength
		e.g. 1mg once a day
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
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12:
13:
14:
15:
16:
17:
18:
19:
20:

Comments

Please do not include medical problems here - these should be discussed with your doctor

About This Form

Fields marked with a red asterisk are compulsory.*

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential. Where appropriate this data is deleted two months after its creation.

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of ordering a repeat prescription.

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Repeat Prescription Request Form