Repeat Prescription Request

To request a repeat prescription, please eneter your personal details below, followed by the name, strength and dosage of the medication you require.

Please allow at least 72 hours before visitng your preferred chemist.

We can only process requests for repeat prescriptions - if you require a new medication you will need to book an appointment or speak to one of our clinicians on the telephone.

Please select the practice location most relevant to this Online Form submission:

Your details

Title

First Name

Surname

Date of birth(DD/MM/YYY)

Your address

Email Address

Mobile Phone Number

Preferred chemist collection

Preferred Chemist

Medication Required

Medication 1(Please include full medication name, strength and dosage)

Medication 2(Please include full medication name, strength and dosage)

Medication 3(Please include full medication name, strength and dosage)

Medication 4(Please include full medication name, strength and dosage)

Medication 5(Please include full medication name, strength and dosage)

Medication 6(Please include full medication name, strength and dosage)

Medication 7(Please include full medication name, strength and dosage)

Medication 8(Please include full medication name, strength and dosage)

Medication 9(Please include full medication name, strength and dosage)

Medication 10(Please include full medication name, strength and dosage)

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Main Surgery • 76 - 78 Upper Wickham Lane, Welling, Kent, DA16 3HQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.