You can use this form to order repeat prescription medicines. If you need to order more than six items at a time, you can submit another form after sending this one in. Your Name (required) Address (required) Town / City (required) Postcode (required) Telephone Email address (required) Date of birth Medication name Drug dose Drug quantity Any other information 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 practice accepts no responsibility for breaches in confidentiality resulting from patients transmissions. By clicking Send you agree to the terms and conditions of using this service.