Form

Please type in the spaces provided using a separate line for each medication you require. When you have finished click 'send' and an email will be sent to the practice with this information.

Email prescription requests are NOT internet shopping! This is a clinical transaction and may only be used to order items previously agreed with your doctor. Furthermore, the doctor who checks the prescription may not be able to sign it without asking you to come in for a consultation or check-up - this is entirely for your safety and health.

May we also recommend that you print a copy of this form for your own records and keep this until you have received your medication from the pharmacist and checked it.

Please note that this email will be sent to the a secure nhs email address at the practice but will NOT be encrypted, by using this form you are acknowledging this fact and that you are happy to proceed on this basis.

Your prescription will be ready to collect in 2 working days

Please type in the spaces provided using a separate line for each medication you require. When you have finished click 'send' and an email will be sent to the practice with this information. Email prescription requests are NOT internet shopping! This is a clinical transaction and may only be used to order items previously agreed with your doctor. Furthermore, the doctor who checks the prescription may not be able to sign it without asking you to come in for a consultation or check-up - this is entirely for your safety and health. May we also recommend that you print a copy of this form for your own records and keep this until you have received your medication from the pharmacist and checked it. Please note that this email will be sent to the a secure nhs email address at the practice but will NOT be encrypted, by using this form you are acknowledging this fact and that you are happy to proceed on this basis. Your prescription will be ready to collect in 2 working days
Full Name	Date of Birth
Address	Email Address
	Telephone Number
What medication would you like to request?










Now please print a copy of this form before pressing "Send"