(PT331) Repeat Prescription Request Form

Repeat Prescription Request Form

Please enter your personal details on this form as they would appear on our records. If we cannot confirm your identity, we will be unable to issue you with a repeat prescription.
Full Name*
Date of Birth*

DayMonthYear
Phone Number*
Email*
Current Home Address*

State / Province

Prescription Delivery
Please indicate if you would like:*

A paper prescriptionYour medication to be dispensed by Fleet Street Clinic
Please indicate if you would like:*

To collect your paper prescription from Fleet Street ClinicYour prescription to be sent to your local pharmacyYour prescription to be posted to you
Please indicate if you would like:*

To collect your medication from Fleet Street ClinicYour medication to be posted to you
Is your delivery address different to the Current Home Address indicated at the start of this form?*

NoYes
Please note there may be an additional fee associated with your postal delivery. Your medication will be posted via Royal Mail Special Delivery and will require a signature upon delivery.
Pharmacy Name*
Pharmacy Contact Email (if known)
Pharmacy Address*

State / Province
Prescription/Medication Delivery Address*

State / Province
Our reception team will be in contact with you to confirm your repeat prescription request details and to discuss payment option.
Please write any additional information and/or comments below.

Sign and Submit
Please read the below before completing the following consent section.

Your privacy: Fleet Street Clinic complies fully with current Data Protection legislation including the General Data Protection Regulation (EU Regulation 2016/679) (the "GDPR") and medical confidentiality guidelines. For further information, our Privacy Notice is available at www.fleetstreetclinic.com/privacy-cookies/.

Please note repeat prescription requests will be reviewed by Fleet Street Clinic clinicians and you may be contacted by a member of the medical team to discuss your request further if necessary.
Please read the below and tick the boxes.*

I confirm that the information provided in this form is truthful and correct to best the best of my knowledge.I consent to Fleet Street Clinic using my information to write a prescription or dispense medication per my indicated preferences.I understand that my information in regards to this prescription may be shared with my registered GP.I understand that I may be obligated to inform my registered GP about my prescription on fulfilment of this request.I consent to my information and prescription being shared with nominated suppliers (e.g., local pharmacy) if indicated.I understand that I can withdraw my consent for future instances and/or change my contact preferences at any time without having to give a reason. Please contact info@fleetstreetclinic.com.
Signature*

Clear
Date Signed*

DayMonthYear
PT331/QM/v1.0/i.05.2023/r.05.2025
Should be Empty:

Repeat Prescription Request Form

Prescription Information

Prescription Delivery

Sign and Submit