Repeat Prescription Request - Abersychan Group Practice

Please make your repeat medication requests by completing the prescription request form below.

We would advise that you order any repeat

Wherever possible we will send it to your local designated pharmacy. If you do not have a designated pharmacy and would like your prescription to be sent to them please let us know who is your chosen pharmacy is when you make your request.

Your Details

First Name

Surname

Date of Birth

NHS number (if known)

Contact number

E-mail Address

Confirm E-mail Address

Preferred Collection Point

Prescription Details

Copy exactly the details from a prescription slip you have received from the practice. Please note that items will only be dispensed if they are included in a prescription from the practice and a medication review is not pending.

Medication Required

Please list all medications required to include Name, Strength / Dosage and quantity required. You can request up to 10 items using this form. Please list individual items below

Item 1 - Medication Name, Strength / Dosage, Quantity

Item 2 - Medication Name, Strength / Dosage, Quantity

Item 3 - Medication Name, Strength / Dosage, Quantity

Item 4 - Medication Name, Strength / Dosage, Quantity

Item 5 - Medication Name, Strength / Dosage, Quantity

Item 6 - Medication Name, Strength / Dosage, Quantity

Item 7 - Medication Name, Strength / Dosage, Quantity

Item 8 - Medication Name, Strength / Dosage, Quantity

Item 9 - Medication Name, Strength / Dosage, Quantity

Item 10 - Medication Name, Strength / Dosage, Quantity

Any comments about your prescription **Not for medical problems**

Important notice - This request form is for repeat medication only. The Practice will be unable to respond to any other messages or queries.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy. This information is not shared with any third party organisations. This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form

Yes