Repeat prescription form – The Elizabeth Courtauld Surgery

Please allow 4 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*
DD slash MM slash YYYY
Email address*
Enter Email Confirm Email
To receive confirmation of your request
Daytime telephone number*
So that we can contact you with any queries
Please 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)*
Other 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 50mg
Quantity 1 - eg 28 tabs*
Item 2
Strength 2
Quantity 2
Item 3
Strength 3
Quantity 3
Item 4
Strength 4
Quantity 4
Item 5
Strength 5
Quantity 5
Item 6
Strength 6
Quantity 6
Item 7
Strength 7
Quantity 7
Item 8
Strength 8
Quantity 8
Item 9
Strength 9
Quantity 9
Item 10
Strength 10
Quantity 10
Item 11
Strength 11
Quantity 11
Item 12
Quantity 12
Strength 12
Additional info
Consent*
I agree to the privacy policy.
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.
Terms & 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
1. The service is provided only to request repeat prescriptions. It is not to be used to request advice or assistance on any other matter.
2. You can only order items listed on the repeat request form attached to your last prescription.
3. If the date for your next review with a doctor or nurse has passed you will be asked to make an appointment.
4. Your prescription will be ready for collection from the surgery two working days after your request has been submitted.
5. 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.
6. An email confirming your repeat request will be sent to the address you provide on the form on the following page.
7. 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.

Terms & Conditions