On-line Repeat Prescription Requests

e-form requests [below] received by 11:45 am will be processed the same day and medication ready for collection after 2 working days

Your Personal details

Your Doctor: Enter Doctor

Patient No: (if known)

Full Name: Enter Name

Date of birth: Enter DOB

Address: Enter Address

Post Code: Enter Postcode

Other Contact details

Email address: Enter EmailInvalid format

Home Telephone: Enter Telephone

Other ways of contacting you:

Prescription requests

Item 1 Strength Quantity

Item 2 Strength Quantity

Item 3 Strength Quantity

Item 4 Strength Quantity

Item 5 Strength Quantity

Item 6 Strength Quantity

Item 7 Strength Quantity

Item 8 Strength Quantity

Additional information:

Acceptance

I accept North Curry Health Centre's conditions for on-line repeat prescriptions (as shown above) Please Accept

Your Doctor's Name is missing
Your Full Name is missing
Your Date of Birth is missing
Your Address is missing
Your Postcode is missing
Your Email Address is missing
Your Email Address format is invalid
Your Home Telephone is missing
Please tick the Acceptance box

We recommend that when using this e-form you print off and keep a copy of the acceptance page [which pops up after the submit button is pressed]

Disclaimer
please read

To use this system, you will have to enter information about yourself that will be sent to us across the internet.

This information is not encrypted, but will be no less secure than a normal email.

We can not guarantee that this information will not be seen by others, but provisions have been taken to protect the data