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Repeat Prescription
Existing patients requiring repeat prescriptions should complete this form and pay the £30 fee at checkout. Prescriptions will be checked and sent to the pharmacist and should be available to order within 5 working days.
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1
Name
*
This field is required.
Only request prescriptions for you own use.
First Name
Last Name
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2
Email
*
This field is required.
Confirmation and payment receipt will be sent to this email.
example@example.com
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3
Date of Birth
*
This field is required.
Required to check against your patient record.
/
You must be over 18
Day
Month
Year
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4
Requested Prescription
Please enter the details accurately from your medication. If unsure please arrange a video consultaiton.
Max 100 words
0/100
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5
Payment
Please click submit to be transferred to secure online payment to complete the process.
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
Remove
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Great Product Name
$20
Quantity:
1
Size:
Small
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ORDER SUMMARY
Total cost
GBP
Prescription Fee
£
30.00
+
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