Prescription ordering form – Hedingham Medical Centre

"*" indicates required fields

Full Name*

Enter your full name here

Date of Birth*

DD/MM/YYYY

Email*

Enter Email Confirm Email

Daytime Telephone Number*

List*

Drug

Quantity and/or Strength eg 1mg once a day

You may request up to twenty separate items. Enter each drug and strength on your prescription. To add more items click on the Plus symbol to the right of your entry.. Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending.

Comments

Please do not include medical problems here - these should be discussed with your doctor