290 Knowsley Road, Bootle, Merseyside, L20 5DQ
Tel: 0151 922 3841
      Home » Repeat Prescription Request Form
Repeat Prescription Request Form
Important Information
You do NOT have to register to order your repeat prescription - it is your choice. If you do not wish to register simply use the form below to place your order.
Patient Details
Full Name: *
Date of Birth: *
Email: *
Confirm Email: *
Day Time Tel: *
Your Doctor:
Collect From:
Medication
Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
  Drug Quantity and/or Strength
    e.g. 1mg once a day
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
Comments
Please do not include medical problems here - these should be discussed with your doctor
About This Form
Fields marked with a red asterisk are compulsory.*
 
 
Personal Information
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential. Where appropriate this data is deleted two months after its creation.

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of ordering a repeat prescription.
 
Home Repeat Prescription Request Form
2016 North Park Health Centre. All rights reserved.    |   Terms of Use   |   Privacy   |   Medical Policies