Boundaries Surgery - Repeat Prescriptions

Please allow two working days for a repeat prescription request to be processed. It is our usual practice to issue prescriptions for a one month supply of medication. In special circumstances where you require a different amount than usual, please let us know why so we can issue extra prescriptions (e.g. an extra month to cover a holiday).

Note that the email account for repeat request forms is checked daily at 12 noon and requests sent after this time will be received the following day.

Last
Name:

First
Name:

D.O.B.:

Email:

Phone:

I would like to request the following medications as listed on my repeat prescription slip:

Drug Name e.g. Paracetamol	Strength e.g. 500mg	Quantity e.g. 28

I would like to request the following medications which I have had before but are not on my repeat prescriptions list (a doctor may need to contact you):
Please do not use this form to ask other medical queries or make non-prescription requests

Collection
I would like to collect my prescription from

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Confidentiality
To use this system you have entered information about yourself that will be sent across the Internet. This information is not encrypted, but will be no less secure than normal email. The practice is unable to accept responsibility for breaches in confidentiality resulting from the use of this form.

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