Northowram Pharmacy - Prescription Service

THE REPEAT FORM IS CURRENTLY INACTIVE

We have an arrangement with the following surgeries to dispense repeat prescriptions to patients -

SURGERY NAMES

This service is only available to patients of these surgeries who have a valid, up-to-date, repeat prescription.

First Names:
Last Name:
Date of Birth:	(dd/mm/yyyy)
Address:
Phone Number:
Email Address:
Surgery:

Please tell us what medication you require. Be specific and check your spelling. Please take all details from your repeat prescription record slip.

Drug Name	Strength

If you require more than 8 items, please submit another request.

Comments (any comments that you may have about this service)

CONFIDENTIALITY - TERMS AND CONDITIONS
The internet is not secure, and the transmission of data to request medication is entirely at the patient's own risk. The Pharmacy accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above and understand that by ticking this box I give my consent for Northowram Pharmacy to order, pick up and dispense this repeat prescription.

Repeat Prescriptions