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The Hollies Medical Practice NHS GP Surgery in Tamworth

Repeat prescription request

Repeat Prescription Request

Who is requesting this medication? *

Myself

On behalf of

Item 1 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 2 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 3 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 4 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 5 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 6 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 7 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 8 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 9 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Item 10 of 10

Type of prescription

Repeat

Acute

When did you last have this medication? *

Why are you taking it? *

Does it help? *

How often do you take it? *

Item Description

Strength

Quantity

Other questions

Additional comments from patient:

If you are requesting on behalf of a patient from a clinical service, please inform us how we can contact you if there are any issues:

Please nominate a pharmacy for your prescription to be sent to, we no longer leave prescriptions to be collected from reception:

Confirmation *

I understand this is not an urgent request form and must wait up to 48 hours before contacting my nominated pharmacy to see if my prescription has been issued.

Confirmation *

I understand that if my prescription is Acute, I must check any responses sent to my email. I will not assume my prescription has been issued.

Consent

I am happy for the surgery to contact me with regards to signing up for online access.

If you are human, leave this field blank.

The Hollies Medical Practice
Tamworth Health Centre
Upper Gungate
Tamworth
Staffordshire
B79 7EA

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01827 217799

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