Surname:           *                         * boxes must be completed

First Name:        *

Date of Birth:     *

Home Address:

                               *

Email Address:  *

Insert the following information as seen on your repeat prescription slip.

Item                                                                             Strength

e.g. Paracetamol                                                       e.g. 500mg

Please Select your Collection Point:      Alliance - Byfleet Assura - West Byfleet Boots - West Byfleet Lloyds - West Byfleet Lloyds - Pyrford Lloyds - New Haw May and Thompson - Sheerwater West Byfleet Health Centre None

                                Any additional Information: 

CONFIDENTIALITY - TERMS AND CONDITIONS:

The Internet is not secure and the transmission of data to request medication is entirely at the patient's own risk.  The Practices accept no responsibility for breaches in confidentiality resulting from patients' transmissions.

* I accept the terms and conditions above (must be ticked or your request will not be processed)