Prescription Request Service

Many thanks for using the Prescription Request Service at the Surgery. Please note that this service can only be used for medication that you have had previously issued at the Surgery. For medico-legal reasons we cannot issue any new medications without you seeing a GP first.

Prescription requests will be processed at 10.00am, 2.00pm, and 4.00pm, Monday to Friday, so do please allow time for us to get your prescription ready and have it signed by your GP. We may contact you if you are requesting a repeat medication and it has been several months since your GP last saw you for a medication review.

The more information you can provide in this form, the easier it will be for our staff to deal with your request.

If your prescription request is urgent, please advise this in the notes section below and then call the Surgery on 0207 245 9333 and we can expedite processing this for you. This should only be done in genuine time-critical situations.

Patient Details
Patient's Name (*required)
Date of Birth - DD/MM/YYYY (*required)
Who is your regular doctor? (*required)

Date of last medication review (if known)

Medication Required
Please note that you can only request up to three months of each medication with this service. Your doctor will require you to come in for a medication review if you have had several repeats of your medication and you haven't been in for a consultation within six months. If you have an arrangement with your doctor to be able to request more than three months at a time, please mention this in the notes section at the end of the form.
Medication 1: Name & Dosage (*required)
Amount of medication requested (*required)
Medication 2
Amount requested
Medication 3
Amount requested
Medication 4
Amount requested
Medication 5
Amount requested
Medication 6
Amount requested

Patient Allergies
Do you have any drug allergies? (*required)
 No Yes
If Yes, please state

Receiving your prescription
How would you like to receive your prescription? (*required)
If By Post or Fax to Pharmacy, please specify address (Note: faxed prescriptions may incur a £30.00 administration charge)
Pharmacy Fax Number (if applicable)
Would you like to be notified when your prescription is ready? (*required)
Preferable email address or phone number (if applicable)
Any additional notes for your prescription

Confirm & send your prescription request
I can confirm the above information is correct to my knowledge (*required)
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