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Special Prescription Request

If you require medication no longer on your repeat list, please complete the form below and either hand in to the surgery or email the form to us at Please note this means you will have to open and save the form on your own computer in order to send it as an attachment to our email address.

Future development of this page will allow the form to be sent automatically on completion but, for the moment, we can only receive the form printed and handed into the surgery or via email.

Special Request order form

Background Information:

The special request order form has been created to improve patient safety.  Recent national surveys indicated there is a high probability of prescription errors when information is taken over the telephone.  For this reason, prescription requests should not be made via telephone.

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