The Grange Practice

Repeat Prescriptions

This is our repeat prescription form, which will allow patients registered at our practice to request a repeat prescription using the form below. We have a number of Terms and Conditions, which you should read before using the repeat prescription form

This form does not use a secure internet connection, and sends the information to the surgery in an unencrypted email. Users should be aware of this, and should only use this form if they accept that their prescription request is transmitted in this way. If not, or if you are in doubt, then you should bring your repeat prescription request to the practice reception.

1. About you, the Patient

We need to know who the repeat prescription is for, so we can assess its validity.

Items marked with a * are required fields. If you can provide further information that we can use to validate your request, such as your NHS number, then please do so.

• Full Name: *

Please enter your full name as registered with us at the surgery.

• Date of Birth: *- -1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31st - - - - - -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember - - - -2010   2009   2008   2007   2006   2005   2004   2003   2002   2001   2000   1999   1998   1997   1996   1995   1994   1993   1992   1991   1990   1989   1988   1987   1986   1985   1984   1983   1982   1981   1980   1979   1978   1977   1976   1975   1974   1973   1972   1971   1970   1969   1968   1967   1966   1965   1964   1963   1962   1961   1960   1959   1958   1957   1956   1955   1954   1953   1952   1951   1950   1949   1948   1947   1946   1945   1944   1943   1942   1941   1940   1939   1938   1937   1936   1935   1934   1933   1932   1931   1930   1929   1928   1927   1926   1925   1924   1923   1922   1921   1920   1919   1918   1917   1916   1915   1914   1913   1912   1911   1910   1909   1908   1907   1906   1905   1904   1903   1902   1901   1900   1899   1898   1897   1896   1895   1894   1893   1892   1891   1890   1889   1888   1887   1886   1885   1884   1883   1882   1881   1880   

We need to identify and confirm who you are, using your date of birth. Please select a day, month and year.

• Address: *

Please enter the address you have registered when you joined the practice.

• Postcode: *

Please enter the postcode you have registered when you joined the practice.

2. In case we need to contact you

We may need to contact you if there is a problem with this repeat prescription request. Please enter either a telephone number or an email address where we can contact you.

• Telephone:

You may enter a contact telephone number, in case we need to contact you regarding your prescription.

or

• Email Address:

You may enter a contact email address, in case we need to contact you regarding your prescription.

3. Your Required Medication

We need to know what medication you require via this repeat prescription. You must enter the name, strength and number requested for each item. You can add further items by pressing "Enter another item".

• Name of Medication 1 : *

Please enter the name of the medication you require.

• Strength of Medication 1 :

Please enter the strength of the medication you require.

• Number Required of Medication 1 :

Please enter the number you require.

[Enter another item]

• Name of Medication 2 : *

Please enter the name of the medication you require.

• Strength of Medication 2 :

Please enter the strength of the medication you require.

• Number Required of Medication 2 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 3 : *

Please enter the name of the medication you require.

• Strength of Medication 3 :

Please enter the strength of the medication you require.

• Number Required of Medication 3 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 4 : *

Please enter the name of the medication you require.

• Strength of Medication 4 :

Please enter the strength of the medication you require.

• Number Required of Medication 4 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 5 : *

Please enter the name of the medication you require.

• Strength of Medication 5 :

Please enter the strength of the medication you require.

• Number Required of Medication 5 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 6 : *

Please enter the name of the medication you require.

• Strength of Medication 6 :

Please enter the strength of the medication you require.

• Number Required of Medication 6 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 7 : *

Please enter the name of the medication you require.

• Strength of Medication 7 :

Please enter the strength of the medication you require.

• Number Required of Medication 7 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 8 : *

Please enter the name of the medication you require.

• Strength of Medication 8 :

Please enter the strength of the medication you require.

• Number Required of Medication 8 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 9 : *

Please enter the name of the medication you require.

• Strength of Medication 9 :

Please enter the strength of the medication you require.

• Number Required of Medication 9 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 10 : *

Please enter the name of the medication you require.

• Strength of Medication 10 :

Please enter the strength of the medication you require.

• Number Required of Medication 10 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 11 : *

Please enter the name of the medication you require.

• Strength of Medication 11 :

Please enter the strength of the medication you require.

• Number Required of Medication 11 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 12 : *

Please enter the name of the medication you require.

• Strength of Medication 12 :

Please enter the strength of the medication you require.

• Number Required of Medication 12 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 13 : *

Please enter the name of the medication you require.

• Strength of Medication 13 :

Please enter the strength of the medication you require.

• Number Required of Medication 13 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 14 : *

Please enter the name of the medication you require.

• Strength of Medication 14 :

Please enter the strength of the medication you require.

• Number Required of Medication 14 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 15 : *

Please enter the name of the medication you require.

• Strength of Medication 15 :

Please enter the strength of the medication you require.

• Number Required of Medication 15 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 16 : *

Please enter the name of the medication you require.

• Strength of Medication 16 :

Please enter the strength of the medication you require.

• Number Required of Medication 16 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 17 : *

Please enter the name of the medication you require.

• Strength of Medication 17 :

Please enter the strength of the medication you require.

• Number Required of Medication 17 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 18 : *

Please enter the name of the medication you require.

• Strength of Medication 18 :

Please enter the strength of the medication you require.

• Number Required of Medication 18 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 19 : *

Please enter the name of the medication you require.

• Strength of Medication 19 :

Please enter the strength of the medication you require.

• Number Required of Medication 19 :

Please enter the number you require.

[Enter another item] - [Hide this item]

• Name of Medication 20 : *

Please enter the name of the medication you require.

• Strength of Medication 20 :

Please enter the strength of the medication you require.

• Number Required of Medication 20 :

Please enter the number you require.

[Hide this item]

4. Notes about your Request

If you have any other information about your Repeat Prescription Request please do so here. This can be used for notes such as:

• Any modifications to your normal Repeat Prescription.
• Items you no longer require.
• Reason for ordering early.

• Notes:

In this area you can enter any text about your repeat prescription request.

5. Collection by Chemist

If you wish to have your Repeat Prescription picked up by a Chemist, then please enter their name in the box below. You must inform the Pharmacy that they should pick up your Repeat Prescription from the Practice in 48 hours.

• Chemist to collect Repeat Prescription:

Please enter the name of the Pharmacy who you will ask to collect your repeat prescription, if any.

6. Anti-Spam

As an anti-spam measure, we also request that you complete the following test. Please enter both words as you see them in the box below. If you have difficulty reading them, then press the upper of the three buttons in the box to get a different test.

7. Submit this request

Before we accept your prescription request, you must tick the box below to show that you have read, and agree with, our terms and conditions below. Once you press the "Submit this Repeat Prescription request" button you will be able to preview and check your request, before it is emailed via the Internet to the surgery staff.

 I have read, and agree with, the terms and conditions set out below. *

Terms and Conditions

1. This Repeat Prescription service is only for patients registered with The Grange Practice.
2. To use this repeat prescription system you must read and agree to all Terms and Conditions listed here.
3. The service is provided only to request repeat prescriptions. It is not to be used to request advice or assistance on any other matter.
4. You can only order items listed on the repeat request form attached to your last prescription.
5. If the date for your next review with a doctor or nurse has passed you will be asked to make an appointment.
6. Where possible, your prescription will be ready for collection from the surgery two working days after your request has been submitted. This may, on occasion, be longer.
7. If your repeat prescription is to be collected by a named Pharmacy, then please record the Pharmacy name in the box. You are required to inform the relevant Pharmacy that they should pick up your prescription.
8. The details you submit will be sent to us by unsecure unencrypted email via the Internet. This means that complete confidentiality is not possible because we cannot guarantee the security of the Internet. If you are not comfortable with this arrangement you must order your prescription in person or by post.
9. The practice cannot be held responsible for any delay in receiving your request, nor any technical failure of the system.
10. Please make sure you order repeat prescriptions in plenty of time.