Repeat Prescriptions Form

Please enter all details below. Please ensure that your contact details (email address and telephone number) are correct.

Please note that if you are registered on Patient Access with us, you are able to request repeat prescriptions directly through the Patient Access service.
If you are registered with Patient Access, you can access the website here.
If you do not have a Patient Access account but wish to request a registration form from us, you can do so here.

Full Name
Date of Birth (dd/mm/yyyy)
Telephone Number
Email Address
Collected by Pharmacy?
If a pharmacy normally collects your prescription, please give the name of the pharmacy. If not, please type No.
Any other information
e.g. Do you require a private prescription?
Items Required
Please enter details as they appear on your prescription

Please check you have entered all requested information correctly. Missing/incorrect information will mean your request will not be processed.

Prescriptions requested before 12:00 noon on a weekday will be ready for collection from the practice from noon the next working day. Those requested after 12:00 noon (or at the weekend or on a public holiday) will be ready for collection from noon two working days later.

If you have arranged for a pharmacy to collect and process your prescription (other than Lloyds Pharmacy at Victoria Park), please allow two extra working days before collecting your medication, i.e. if you put in your prescription request on Monday morning, your medication will be ready for collection from noon on Thursday.


The information submitted on these forms is sent to us via normal (non-encrypted) email, and we cannot guarantee that the information will not be seen by others. We accept no responsibility for the loss or interception of data before it reaches our server.

Confidentiality notice regarding prescriptions

If you ask a friend or relative to collect or order your prescription, please be aware that they will be able to see all of the medication you have been prescribed (not just the ones that are ordered), as well as any doctor's notes which may be attached to the script. Medication queries may also be discussed with them.

By asking another person to collect/order your medication it will be assumed that you are giving consent for them to have access to this information.