Special Request Prescriptions

You can request an online Special Request Order Form below to order medications that do not appear on your repeat prescription list. Please complete a form for each item.This service is only available for registered patients.

Please allow at least 72 hours (3 working days), before your Prescription will be ready for collection.

Prescription Special Request Form
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
If you do not know who your GP is insert “not known”

What Medication do you require?

e.g. 5 mg tabs
Is this on your repeat? *
Insert “not known” if unsure
Collect from: *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
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