Repeat Prescription Request Form (DVC and GMS Patients)
Prescriptions are typically issued during an in person consultation and a plan put in place for repeat prescription requests. If it has been more than 6 months since you have consulted your doctor or you are taking medications that require blood-test monitoring and/or a blood pressure check, we may advise you that a consultation is necessary before your repeat prescription can be issued safely.
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Nominated Pharmacy
*
Enter the name and address of the pharmacy you'd like to collect the prescription from.
Required medication
*
Please make us aware of the medication & dosage
Submit
Should be Empty: