Please allow 2 working days before collecting your prescription. Remember the details you submit will be sent to us by unencrypted email via the Internet. This means that complete confidentiality is not possible because we cannot guarantee the security of the Internet. If you are not comfortable with this arrangement you may prefer to order your prescription in person or by post.

 Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be sent.

First Name:*
Last Name:*
Date of birth:*
Patient No: if applicable
(Click here if you don't know your patient number)
Email address:*
(to receive confirmation of your request)
Daytime telephone number:*
(so that we can contact you with any queries)

     Click here to see how your printed prescription relates to the form

Item Strength Amount
eg Atenolol eg 50mg NB:If required please type "percentage" not the symbol "%". eg 28 tabs
Additional information
Note: This will clear the entire form.