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

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Usual GP *

If you do not know who your GP is insert “not known”

What Medication do you require?

Name of Medication *

Dose *

e.g. 5 mg tabs

Quantity *

Is this on your repeat? *

Yes

Why do you take this? *

When did you last have this? *

Insert “not known” if unsure

Collect from: *

Well Place Pharmacy

High Street Pharmacy

Deliver (Housebound only)

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.

I consent to the practice collecting and storing my data from this form.

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