Prescription order form

Please only order the item(s) you require. Prescriptions will be ready for collection 48 working hours after ordering. We recommend using the NHS App to order your medication.

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Name *

First

Last

Date of birth *

Phone number *

This is in case we need to contact you if there are any issues with your request.

should number of

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Item(s) required

If you wish to add more items, use the + icon at the end of the row to add more.

Drug name and dosage *

i.e. Citalopram 20mg

Amount *

i.e. 28 capsules

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Where should we send your prescription? *

• My usual nominated pharmacy
• A different nominated pharmacy

Which pharmacy should we send your prescription to? *

Please provide the name of the pharmacy and its location.

Submit prescription request