Request Medication Form - Dearden Avenue Medical Practice

If you do not have a Patient Access account, you can use this form to request any repeat prescriptions from the Practice.

Please allow 2 working days before collecting your prescription.

In future you may wish to register for the NHS App to have the ability to Book or Cancel an Appointment, Request a Repeat Prescription, View your Medical Records and more without visiting the practice.

Order Medication

Please complete the online form below to request a repeat prescription.

Title

First Names

Surname

Date of Birth

Address

Street Address Address Line 2 City Postcode

Contact Number

Email Address

Enter Email Optional Confirm Email Optional

Enter each medication and strength on your prescription

Medication

Strength

Dose

Pick Up Point Optional

Additional Notes Optional