BEECHLEY MEDICAL CENTRE

Repeat Prescription Request

Please note that the preferred method of ordering a repeat prescription is to use the tear off slip which was attached to your last prescription.

Please also note that the practice cannot respond to e-mails

If you choose to order using this on line form please ensure that all required fields are completed. In order for a prescription to be issued, your details must exactly match those contained in your medical records held at the surgery.

You should be aware that submission of this form will involve transmitting personal details about yourself across the Internet. Your information is encrypted during transmission, but we cannot offer an absolute guarantee of privacy and use of this method is entirely at your own risk. However when the information reaches the practice it will be held totally secure. If this matter is of concern to you then you should use one of the alternative methods of ordering a repeat prescription.

Please note that your prescription will be ready for collection from the surgery 48hrs from when the surgery NEXT opens after your submission.

If you have requested that your prescription be forwarded to a chemist for dispensing please allow a further 24hrs before collecting your medication.

* indicates required field

*Your Email Address:

*Your Full Name:

*Telephone number
(for security purposes we can only accept a landline number):

* Address Line 1:

* Address Line 2:

     Address Line 3: (if applicable)

* Post Code:

* Date of birth:

Day:(dd) Month:(mm) Year:(yyyy)

* Doctor:

Please enter full details of the medication you require including Strength, Dose & Quantity in the boxes below: (1 item per box please.) If you require more than 6 items a second submission will be necessary.

Medication Strength Dose Quantity
1.
2.
3.
4.
5.
6.

Please enter any other information, such as reasons for early requests, in the box below.

* Please indicate if you wish to collect your prescription directly from your chemist.
Yes: No:

If you have opted for collection from a chemist please indicate which below.

Alexanders Boots Borras Brymbo
Brynteg Chapel St Garden Village Holt Road
Kings Mills Rhosddu Rhostyllen St.Georges Cres
Strathmore Superdrug

If you wish to keep a copy of your repeat prescription order form please Click the printer logo, BEFORE clicking the Submit Order button
print order form

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