Glastonbury Health Centre

REPEAT PRESCRIPTION REQUEST

Repeat prescriptions will be available for collection at the surgery after two working days following your order.

PLEASE READ

To use this system, you will have to enter information about yourself that will be sent to us across the internet.

This e-form information is not encrypted, but will be no less secure than a normal email.

We can not guarantee that this information will not be seen by others.

Your personal details

Your Doctor
Patient Number (if known)
Full Name	Enter Name
Address	Enter Address
Post Code	Enter Postcode
Date of Birth	Enter DOB

Other contact details

E-mail address	Enter EmailInvalid format
Home telephone no.	Enter Telephone
Other / Mobile

Prescription requests

Item 1		Strength	Qty
Item 2		Strength	Qty
Item 3		Strength	Qty
Item 4		Strength	Qty
Item 5		Strength	Qty
Item 6		Strength	Qty
Item 7		Strength	Qty
Item 8		Strength	Qty
	Additional information

Collection

I will collect from:

Acceptance

Please confirm your acceptance of Glastonbury Health Centre's Practice's terms and conditions for online repeat prescription requests by inserting your name in the box below.
Accepted by	Enter Name
Your Full Name is missing Your Address is missing Your Postcode is missing Your Date of Birth is missing Your Email Address is missing Your Email Address format is invalid Your Home Telephone is missing Your 'Accepted By' name is missing
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