Wufoo

Repeat prescription request form

Enter your details below to request a repeat prescription. This is only be used for medicines that are authorised by your doctor to be used as a repeat prescription.

This is not an encrypted message, if you are concerned of the possibility of someone intercepting your information please post in your request or put it in the repeat prescription letterbox at the surgery in the normal way.

IMPORTANT: Please make sure you leave 2 working days before collection, weekends don't count because we are closed. However expect a longer delay if you are asking for a medication you have not had before or for some time, or if it has been recently started by a hospital doctor as our duty doctor will need to check it for accuracy.

Enter name here * First Last
First and last names must be entered
Date of birth * DD / MM / YYYY
Must be filled in to ensure your identity
please enter your Email address in case we have a query *
Medicine(s) requested *

Type the name of the medicines you require
Collect prescription from *
Moors pharmacy Boots pharmacy Ferndown Pharmacy West Moors surgery I usually collect my dispensed medicines from 3 Legged Cross surgery

Where would you like to pick up your prescription from?
Do Not Fill This Out