Repeat Prescription request


If you do not have a Patient Access account, you can use this form to request any repeat prescriptions from the Practice. If you need to order acute medications, please contact the surgery.

Please allow 2 working days before collecting your prescription.

In future you may wish to consider registering for our Online Services. The Online Services system remembers which medications you are on and makes requesting repeat prescriptions faster and easier.

Repeat Prescription Request form

    Required fields are indicated by *

    Are you completing this form on behalf of:

    About you


    Name(s) as it appears on the patient's passport.


    Name(s) as it appears on the patient's passport.


    The one used to register with your GP.


    Your date of birth is used to verify your identity



    As on your medical record.


    This phone number will be used for all correspondence relating to this request.


    This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

    About the patient


    As it appears on the patient's passport


    As it appears on the patient's passport


    The one registered with the patient's GP


    Patient's date of birth is used to verify your identity



    As on the patient's medical record.

    About you




    Your date of birth is used to verify your identity



    As on your medical record.


    This phone number will be used for all correspondence relating to this request.


    This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

    Please continue completing the form below











    If you answer 'yes' to any of the following questions, please book an appointment in the same week.













    Please book an appointment if you would like to discuss contraception.


    Please use the blood pressure machine in the reception area or visit a local pharmacy



    A scale is available in the reception area


    A height measuring station is available in the reception area


    If you are over age 25 you should have had a cervical smear test. If you have had a smear test, but it was more than 3 years ago, please book an appointment with the practice nurse for a repeat test.


    Please read the following leaflet.
    HRT and Breast Cancer Risk Information