Private Script Order

Repeat Medication Order Form - Private Prescription

* Indicates required field

Name *

First

Last

Address *

Date of Birth *

Phone Number *

PATIENT TYPE *

Regular GP *

Select Your Preferred Pharmacy. We will arrange for your prescription to be passed to any of the Pharmacies listed below *

Please list Long Term Medications Required below [Medication name, strength and dosage is required] If medication is not listed in full we can not issue this prescription request. e.g. we are unable to issue requests such as "usual medications", "full prescription", "blood pressure tablets". N.B. Antibiotics are not repeat items and can not be requested on this form. Thank you for your understanding. *

Please allow 3 working days for your Repeat Prescription to be prepared and sent to your choice of Pharmacy. It is important to list your medication names, strength and dosages as omitting this information may result in us being unable to follow up on this request. Please note only long term medications can be requested using this form. Requests for antibiotics or non chronic medication can not be processed. Please do nominate a pharmacy and we will notify them directly. Please note we are unable to respond to other query using this form. Please Click on Submit & Pay to arrange online payment and forward your request. Many thanks.

Submit & Pay

​Repeat Medication Order Form - Private Prescription

Repeat Medication Order Form - Private Prescription