Radford Medical Practice

 

Friday 21 November 2008
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Repeat prescription request form

You can use this form to ask your doctor for a repeat prescription if:

Please type the information into the form exactly as it is on your paper form. If the details you send do not match, we may not be able to give you a repeat prescription.

WARNING Electronic mail is fairly secure but your information could be seen by someone other than practice staff. If you are concerned about this, please bring your paper form to the surgery.

Your name:

Your reference number or date-of-birth:

If you do not know your reference number, which is on the repeat prescription form, please type your date of birth like this: 28/11/1964

Your address:

Your doctor's name:

The date of your prescription:

The medicines you need (please type details of each medicine on a new line):

Your review date:

Your electronic mail address:

Please choose the surgery where you would like to collect your prescription:
    Nottingham Trent University Student Health Centre
    Radford Medical Practice

If your prescriptions usually go straight to the chemist, please type the name of your chemist here:


Example of a repeat prescription request form
Example of a repeat prescription request form

Your form may not look exactly like this but it will have the same information on it.
The parts highlighted in yellow are the ones you need to copy into the online form on this page.

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