Request Form - Bruntsfield Pharmacy

Repeat Medication Request Form

Please allow for a full 4 working days for your prescription to be processed by the Practice and your Pharmacy. Please take that into consideration when ordering your medications and give yourself enough time.

First Name

Last Name

Phone Number

Date Of Birth

Address

Postcode

Please give all drug names you require, in full. You should only use this form if you are requesting medicines that are on your repeat medication re-order form (on the counterfoil of your last prescription).

Drug Name

Strength (e.g. 10mg)

Quantity (if known)

Drug Name

Strength (e.g. 10mg)

Quantity (if known)

Drug Name

Strength (e.g. 10mg)

Quantity (if known)

Drug Name

Strength (e.g. 10mg)

Quantity (if known)

Drug Name

Strength (e.g. 10mg)

Quantity (if known)

Drug Name

Strength (e.g. 10mg)

Quantity (if known)

Select Your GP Surgery

I would like Bruntsfield Pharmacy to (please select where appropriate):

COLLECT my repeat prescription from the surgery.

DELIVER my medicine to my home. Collect from pharmacy and receive text alert notification when your prescription is ready to collect.

I declare that the information l have provided is accurate and complete.

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Repeat Medication Request Form

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