Glinton Repeat Prescription Form

Glinton Surgery Repeat Prescription Form

If this is your first visit here since we rebuild our website then you will not be able to retrieve your previously SAVED USER details from here. If you cannot remember them then please open the old form here. Then copy the details into THIS form and SAVE them. But in future only use this form as the old form will eventually be removed. This is a temporary measure to ease inconvenience to our patients. You only need to do this once. Apologies for any inconvenience this may cause. medicine

Please read before completing the form. Items marked with an are mandatory, but the more information you supply the easier it will be for us to contact you should there be a problem or delay with the order. Fields coloured red are incomplete or incorrect. Please correct them and re-submit the form. Additional help is available by clicking the symbol.

User name		User	Sample Repeat Prescription
Patient name
Address
Date of birth	(dd/mm/yyyy)
Home Tel.
Email address

The following information as seen on the right hand side of your repeat slip. Description, dose and strength must all be entered to ensure we can prepare your repeat prescription order..

	Item Description	Dose	Strength
Item 1*
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8

Additional information	None

Please allow two working days for your prescription to be prepared. Collect your prescription from your usual delivery location

Revised: If you experience any technical or display problems with this form or confirmation emails then please email: admin@deepingspractice.co.uk