Site last updated
26/07/2005

Repeat Prescription request form:

You may request your repeat prescriptions by e-mail. Please allow 2 working days for your request to be processed: Thank-you.

Please provide the following contact information:

*Name

*Date of Birth
DD/MM/YY

Address

Address (cont.)

Town

Post Code

Home Phone

*E-mail

* Required fields
Please Complete Prescription Request Details

QTY Item and Strength i.e. ug/mg/g/mls
Please indicate which Surgery you would like to collect your prescription from-
Burton Surgery
Bransgore Surgery
Any other Information-e.g. You could indicate a Chemist to which you would like your prescription sent.
I understand that e-mail cannot be guaranteed to be totally secure and confidential.
The Practice cannot take responsibility for problems that may arise by making use of this on-line facility.
If requests cannot be acted upon immediately, then an e-mail will be sent asking for clarification of the request or asking you to make an appointment.
Please indicate below that you accept the terms and conditions and then submit your request.
I Accept the Terms. (you must enter "Yes" to submit your request)