Albany House Surgery > Clinics & Services > Practice Services > Prescription request

Prescription request

Please note that we aim to complete your request within 72 Hours. This is not for urgent requests.

Repeat Prescription Request

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Prescription Items

Copy exactly the details from a prescription slip you have received from the practice.

Please note that items will only be dispensed if they are included in a prescription from the practice and a medication review is not pending.

Item 1 – Medication ( please include the strength and quantity )

Item 2 – Medication ( please include strength and quantity )

Item 3 – Medication ( please include strength and quantity )

Item 4 – Medication ( please include strength and quantity )

Item 5 – Medication ( please include strength and quantity )

Item 6 – Medication ( please include strength and quantity )

Item 7 – Medication ( please include strength and quantity )

Item 8 – Medication ( please include strength and quantity )

Item 9- Medication ( please include strength and quantity )

Item 10 – Medication ( please include strength and quantity )

Please select your choice of chemist for this prescription * Please select your choice of chemist for this prescription

Any special information about your request?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
Please note: For reasons of privacy this form will not store your details or medication request. There is no email acknowledgement with this service. Once you send this form a notification message will appear to indicate successful submission.

🔓Checkboxes

I understand and am happy that I have completed this form accurately and have selected my chosen chemist. I understand that this is a non urgent request

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Prescription request

Prescription Items

Privacy Policy

Albany House Surgery

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