* = Required field |
First
Names: |
* |
Last
Name: |
* |
Date
of Birth
(dd/mm/yyyy): |
* |
Email
Address: |
* |
Phone
Number: |
|
Your
Usual Doctor: |
|
Please tell us the drugs you require. Be specific and check
your spelling. Please take all details from your repeat prescription record slip. |
|
If
you require more than 10 items, please submit another request.
|
Collection
Point : |
* |
Comments:
(any comments that you may have about this service, or additional medication) |
|
CONFIDENTIALITY
- TERMS AND CONDITIONS:
The internet is not secure, and the transmission of
data to request medication is entirely at the patient's own risk. The practice
accepts no responsibility for breaches in confidentiality resulting from patients'
transmissions.
|
|
