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Javascript DHTML Tree Menu Powered by dhtml-menu-builder.com Repeat Prescriptions
     
 
    ON-LINE PRESCRIPTION REQUEST
   
Important Information - Please Read

Repeat prescriptions will be available for collection at the surgery after two working days following your order.

 

PLEASE READ

To use this system, you will have to enter information about yourself that will be sent to us across the internet.

This e-form information is not encrypted, but will be no less secure than a normal email.

We can not guarantee that this information will not be seen by others.
Your personal details
Your Doctor
Patient Number (if known)
Full Name Enter Name
Address Enter Address
Post Code Enter Postcode
Date of Birth Enter DOB
Other contact details
E-mail address Enter EmailInvalid format
Home telephone no. Enter Telephone
Other / Mobile

 
Prescription requests
Item 1 Strength Qty
Item 2 Strength Qty
Item 3 Strength Qty
Item 4 Strength Qty
Item 5 Strength Qty
Item 6 Strength Qty
Item 7 Strength Qty
Item 8 Strength Qty
 
Additional information

 
Collection
I will collect from:
Acceptance
Please confirm your acceptance of Wells City Practice's terms & conditions for online repeat prescription requests by inserting your name in the box below.

Accepted by

Enter Name
Your Full Name is missing
Your Address is missing
Your Postcode is missing
Your Date of Birth is missing
Your Email Address is missing
Your Email Address format is invalid
Your Home Telephone is missing
Your 'Accepted By' name is missing
   
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