Please Note: Complete confidentiality for this type of repeat prescription request can
not be guaranteed. If you have an issue with this please feel free to use
our normal repeat prescription service. Please allow 24-48 business hours to complete request.
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Patients Name * |
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Date of Birth * |
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Address |
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Contact Tel.* |
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Email Address |
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You must provide this information.
The items requested below MUST be on your regular repeat medication
list. |
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Item Description
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Dose
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Quantity |
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(e.g.
Paracetamol) |
(e.g. 500mg) |
(e.g. 100) |
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Item 1 |
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Item 2 |
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Item 3 |
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Item 4 |
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Item 5 |
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Item 6 |
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Item 7 |
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Item 8 |
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* Preferred Pharmacy Name and City * |
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