Repeat Prescription

We can dispense NHS repeat dispensing prescriptions issued by your doctor. Ask us for more information about this service.

Repeat Prescription Order Form

Repeat prescription order form

Your Details
Name*
First Last
Date of Birth*
Day
Month
Year
Address*
Street Address Address Line 2 City County Post Code Country
Contact Number: Mobile*
Contact Number: Home
Contact Number: Work
Email*
Enter Email Confirm Email
GP Surgery / Doctors Details
Doctor's Surgery*
Doctor's Address*
Please enter your doctor's full mailing address here including the post code.

Street Address Address Line 2 City County Post Code Country
Doctor's Phone Number*
NHS Information
Do you normally pay for your NHS prescriptions?*
NHS Exemption*
As you have indicated you are exempt from NHS prescription charges, please select your exemption
NHS Exemption / Certificate Number*
Medication Request
Number of Items*
Qty*
example: 36
Name*
example: Metformin
Strength*
example: 500mg
Form*
example: tablets
Dosage*
example: three times
Qty*
example: 36
Name*
example: Metformin
Strength*
example: 500mg
Form*
example: tablets
Dosage*
example: three times
Qty*
example: 36
Name*
example: Metformin
Strength*
example: 500mg
Form*
example: tablets
Dosage*
example: three times
Qty*
example: 36
Name*
example: Metformin
Strength*
example: 500mg
Form*
example: tablets
Dosage*
example: three times
Qty*
example: 36
Name*
example: Metformin
Strength*
example: 500mg
Form*
example: tablets
Dosage*
example: three times
Consent & Delivery / Collection Information
Delivery Method*
Address*
As you require delivery to an alternative address, please enter the full address with post code here.

Street Address Address Line 2 City County ZIP / Postal Code Country
- 1. I hereby authorise Hemants Pharmacy to collect, either in person or by means of electronic transfer, my prescription from the surgery I have indicated above, on my behalf.
- 2. I agree to inform Hemants Pharmacy of any changes to my circumstances and / or medication.
- 3. Hemants Pharmacy will request your prescriptions but is not responsible for any delays caused by the surgery.
- 4. I have read, agree and consent to the above statement.
Please note: If this is the first time you have requested this service from us, you will be asked to complete and sign our "Prescription Collection & Delivery form" at the point of your initial prescription collection/delivery, a hard copy of which will be included with your prescription medication.
Accept Patient Consent & Agreement*
CAPTCHA

Repeat Prescription

Repeat Prescription Order Form

Your Details

GP Surgery / Doctors Details

NHS Information

Medication Request

Consent & Delivery / Collection Information