Repeat Prescription Order

Repeat Prescription Request Form

Please ensure all information is accurate and matches your current prescription.

First Name

Last Name

Date of Birth

Medical Card Number (if applicable)

Pharmacy Name & Address

Latest Readings (Required)*

Blood Pressure: ____/____ mmHg

Heart Rate: ____ bpm

Required For Patients Under 18 *

Weight

Date of Readings

IMPORTANT: These readings are essential for your prescription review. You can use readings taken at home with your own blood pressure monitor, or readings from a recent pharmacy or GP visit (within the last month). We cannot process your prescription renewal without these readings. If you don't have a blood pressure monitor at home, many local pharmacies offer free blood pressure checks.

Drug 1

Drug 2

Drug 3

Drug 4

Drug 5

Your prescription will be ready for pickup at your pharmacy within 24 hours after we receive it, during business hours (Monday to Friday, 9 AM to 5 PM).

I confirm I have read and understood the Privacy Notice regarding how my personal data will be processed.View policy

I explicitly consent to the processing of my health data for prescription management purposes.

I confirm it has not been more than 12 months since my last 30-minute zoom review appointment (required annually as per NICE guidelines).

I confirm there have been no significant changes to my medical history since my last review appointment.

Under-18 patients requiring parental consent.

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