Welcome to Culloden Medical Practice

Please Note : This form is sent to us via computers that do not belong to the NHS in a non-encrypted format. Complete confidentiality for this type of repeat prescription request can not be guaranteed. If you have an issue with this please feel free to use our normal repeat prescription service.

Repeat Prescription Form

Patient's Name *
Date of Birth *
Email Address
Address *
Contact Tel: *
Date
Your Doctor *
* Means you must provide this information

Please select from the list below where you want to collect your prescription:

Please give all drug names in full, including dosage, strength as described on your previous prescriptions. You should only use this form if you are requesting medicines that are on your repeat medicatJanuary 27, 2009 form, please either hand in, post or fax your request.
	Item Description (e.g. Paracetamol)	Quantity (e.g. 100)
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10

Comments about your prescription * Not for medical problems *

Please allow 48 hours notice, excluding week-ends
(Please allow 2 full working days)

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