Giggs Hill Surgery - Repeat Prescription Request Form

You may use this form to request a Repeat Prescription.

Warning: gmail, yahoo, msn and hotmail email addresses. Please enter those email addresses with a double g/y/m/h e.g. ggmail to prevent this form failing to send.

We will only accept requests for prescription items that are listed on your Repeat Prescription counterfoil. The item has to be authorised, i.e. not in need of review by a Doctor, as indicated on the Repeat Prescription request form.

You must include a valid email address so that we can notify you of a problem. Although this form is not encrypted the data is saved on our server and collected via the internet, so it is not 100% secure. If you use your unique "AI code" found on your Repeat Request form (see example) you need only enter the first letter of your surname and forename for security.

Please use your TAB key or Mouse to navigate (*=required field)

Surname*

Forename*

Date of Birth*

Email*:

AI code

Telephone*

Drug Name

Strength e.g. 100mg

Form

Collection Point

To ensure you are human! Please enter the first name of Dr Matthews

Please allow the usual 2 working days for the prescription to be processed. Thank you for using this form