Patient repeat medication request form – Uplands & Mumbles Surgery

To order repeat medication, please complete all fields on the online form below.

Ensure all information is accurate to avoid delays in processing your request.

"*" indicates required fields

Name*

First Last

Date of birth*

Daytime telephone number*

Please use the (+) button at the end of the row to add as many rows as you need for your medications.

List*

Item 1 - eg Atenolol

Strength 1 - eg 50mg

Quantity 1 - eg 28 tabs

Please supply the name and location of your preferred pharmacy*

Do you want your prescription sent electronically if the pharmacy is EPS (Electronic Prescription Service) enabled?*

Yes

This will reduce the time needed to send the prescription to your nominated pharmacy once signed.

Do you need to tell us anything else about your request?

Information is accurate and complete*

Yes, the information I have given above is accurate and complete

Not for urgent medical help*

Yes, I understand this form is NOT for urgent medical help