Repeat Prescription Request

Do you need to re-order your medication? You can order repeat prescriptions online.

You must be registered with the practice before we can accept your request.

PLEASE NOTE THAT THIS FORM IS FOR ORDERING REPEAT MEDICATION ONLY. DO NOT USE THIS FACILITY FOR REQUESTING MEDICAL ADVICE.

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Prescription Items

Copy exactly the details from a prescription slip you have received from the practice.

Please note that items will only be dispensed if they are included in a prescription from the practice and a medication review is not pending.

Item 1

Item 2

Item 3

Item 4

Item 5

Item 6

Item 7

Item 8

Item 9

Item 10

Special Medication Request

Please Note: Special requests may not be authorised by the Doctor.

Name and address of your Pharmacy for collection *

We will send your prescription to the local pharmacy of your choice. Please arrange this service with your pharmacy and collect from them — not the surgery.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Practices Portland/Hurlford	01563 522411
NHS 24	111

Repeat Prescription Request

Prescription Items

Privacy Policy

Portland Medical Practice

Telephone