Repeat Prescription Form - Monks Park Surgery

This form is for requesting repeat prescriptions only.

If you have a medication query, please contact the prescription team directly by emailing bnssg.prescriptionscmp@nhs.net or by choosing option 2 on the main line telephone number.

Please allow up to 3 working days for your prescription to be ready. This does not include weekends, and therefore it may take longer for us to get back to if your form was submitted on a Friday and if there is a Bank Holiday.

If there are any problems with your request a member of the team will be in contact with you.

Surname

First Name/s

Your Date of Birth

NHS Number

An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website

Email Address

Please provide an email address so we can inform you the status of your request. If you do not have an email please put n/a

Medication Items

Please list the chosen medication which you would like to reorder. We cannot accept requests if you've never had the medication before.

Your Chosen Chemist and Location

Hospital Dates

If you have recently been in hospital, please include the date you were discharged.

Any other comments

Yes, I give permission to store and process my data

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