Repeat Prescription Request

About This Form:

Welcome to our Prescribing Team online ordering form.

If you are not registered for online services, you can use this form to request any repeat prescriptions from your surgery. Please allow 3 working days before collecting your prescription from your nominated pharmacy.

Note: The information you enter into this form is not stored by our website. It is converted to a PDF document and securely transferred to our Prescribing Team via NHSmail.

By proceeding with this form, you are consenting for our Prescribing Team to access your medical records to process your request.

Last Updated: 10/06/2024

Patient Details

Please tell us which is your usual surgery *

Arnewood

Barton

New Milton Health Centre

Webb-Peploe

Your full name including forename, surname and any middle names *

Date of Birth *

Contact Address *

Contact Telephone Number *

Contact email address *

Your Prescription Request

Please only order your medication when you are down to your last 7 days worth of tablets. If you submit a request before your medication is due to be ordered, then your request may be declined.

If we need to get back to you, you will be contacted via the contact telephone number or email you have provided.

Note: A representative must request medication for anyone under the age of 13 years.

Please write the Medication Name, Strength, Amount and Dosage like the example below:

Senna 7.5mg tablets - 60 tablet - take 1 or 2 at night

Please write the Medication Name, Strength, Amount and Dosage (use a separate line for each medication *

You may write additional notes related to your prescription request here:

Nominated Pharmacy

All prescriptions will be sent electronically to your usual chosen pharmacy. If you would like to change this pharmacy, please provide details of the new pharmacy below.

Pharmacy Name

Pharmacy Address

Your Request

Your request will be processed within three working days. We will only contact you if there are any issues when processing your request. If you have any queries regarding this prescription, please contact your pharmacy first.

Did you know you can also use the NHS App, NHS Website or SystmOnline to order your repeat prescriptions? For more information about accessing Online Services please visit Access Online Services - Coastal Medical Partnership for more information.

I have read and understood all the conditions of using this form *

Yes

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Repeat Prescription Request

Further Information