Bolton House Surgery - Repeat Prescriptions

Please Note:

  1. All repeat prescriptions take two clear working days to be processed.
  2. This form is sent to us via computers that do not belong to the NHS in a non-encrypted format. Complete confidentiality for this type of repeat prescription request can not be guaranteed. Please feel free to use our normal repeat prescription service.
  3. Items marked with an * are required
Forename *
Middle Name
Surname *
Date of Birth *
Address *
Telephone *
Mobile
Email
   
Medication 1 *
Strength 1 *
Dose 1 *
   
Medication 2
Strength 2
Dose 2
   
Medication 3
Strength 3
Dose 3
   
Medication 4
Strength 4
Dose 4
   
Medication 5
Strength 5
Dose 5
   
Medication 6
Strength 6
Dose 6
   
Notes
Your Doctor's Name *
   
Please check ALL of the above details before submitting the form, as any incorrect information will delay your prescription being processed and may cause for the repeat prescription to be ignored.