Altwood Pharmacy Repeat Prescription Order Form

 
Asterisk (*) Indicates Required Field:
Patient's Name: *
Patient's Date Of Birth: *
 
dd/mm/yyyy
Patient's Address: *
 
Please include Postcode
Patient's Telephone Number: *
 
Please include area code
Patient's E-mail Address:
 
Optional
Doctors Surgery: *
 
If your surgery is not listed here, please contact us for further help.
Do you normally pay for your NHS Prescriptions? *
NHS Exemption:
 
If you are exempt from prescription charges please specify your exemption
NHS Exemption Number:
 
Please provide your exemption card number if you have one
Repeat Item 1: *
 
Please include Drug name, Strength & form ( e.g Tablets / Capsules / Liquid )
Repeat Item 2:
Repeat Item 3:
Repeat Item 4:
Repeat Item 5:
Repeat Item 6:
Repeat Item 7:
Repeat Item 8:
Repeat Item 9:
Repeat Item 10:
Notes & Comments:
 
Any other information that may be useful
Please Select Delivery Method: *
Delivery Address:
 
If different from patient's Address, Please include postcode
I hereby authorise Altwood Pharmacy to collect, either in person or by means of electric transfer, my prescription from the surgery shown above on my behalf I agree to inform Altwood Pharmacy of any changes.:  *
 
You Must select this Box to Continue


 

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