Repeat prescription form Please allow 2 working days before collecting your prescription. Remember the details you submit will be sent to us by unencrypted email via the Internet. This means that complete confidentiality is not possible because we cannot guarantee the security of the Internet. If you are not comfortable with this arrangement you may prefer to order your prescription in person or by post. Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be sent.Name* First Last Date of birth* Email address* Enter Email Confirm Email To receive confirmation of your requestDaytime telephone number*So that we can contact you with any queriesPlease note: The Surgery now operates the Electronic Prescription Service. If you would like the surgery to send prescriptions directly to a pharmacy, please nominate a pharmacy by using the drop down box below.Where will you collect your prescription? (please select one)*Collect from surgeryCo-Op/Andrews, HalsteadBoots, HalsteadSolar, HalsteadBoots, Earls ColneDay Lewis, Sible HedinghamOther, please specify in box belowOther location to send prescription (only complete this box if you selected Other in the list above):You can add up to 12 items on this form. As you type in each item another set of boxes will appear.Item 1 - eg Atenolol*Strength 1 - eg 50mgQuantity 1 - eg 28 tabs*Item 2Strength 2Quantity 2Item 3Strength 3Quantity 3Item 4Strength 4Quantity 4Item 5Strength 5Quantity 5Item 6Strength 6Quantity 6Item 7Strength 7Quantity 7Item 8Strength 8Quantity 8Item 9Strength 9Quantity 9Item 10Strength 10Quantity 10Item 11Strength 11Quantity 11Item 12Quantity 12Strength 12Additional infoTerms & Conditions You can request a repeat prescription by completing and submitting an online form. By completing this form you agree to read and accept our terms and conditions Before requesting online repeat prescriptions you will need to register for the service by speaking to our reception staff. The service is provided only to request repeat prescriptions. It is not to be used to request advice or assistance on any other matter. You can only order items listed on the repeat request form attached to your last prescription. If the date for your next review with a doctor or nurse has passed you will be asked to make an appointment. Your prescription will be ready for collection from the surgery two working days after your request has been submitted. Absolute confidentiality is not possible because we cannot guarantee the security of the Internet. If you are not comfortable with this arrangement you may prefer to order your prescription in person or by post. An email confirming your repeat request will be sent to the address you provide on the form on the following page. The practice cannot be held responsible for any delay in receiving your request, nor any technical failure of the system. Please make sure you order repeat prescriptions in plenty of time.