First Name:*

 

Surname:*

Email:*

Date of Birth:* (DD-MM-YYYY)

Work Tel No:

Home Tel No:*

Mobile:

Fax No:

Address:*

The following information as on your repeat slip:

 

 

 

 

MEDICATION

STRENGTH

QUANTITY

Request 1

Request 2

Request 3

Request 4

Request 5

Request 6

Request 7

Request 8

Additional Info:

Please select where you wish to collect your prescription from*

If you wish to collect your prescription from another location please specify in the Additional Info box above.

 

 

 

 
          

Prescriptions will be ready in 2 working days.


IMPORTANT NOTE: WE ARE SORRY FOR THE INCONVENIENCE BUT WE DO NOT TAKE PRESCRIPTION REQUESTS OVER THE TELEPHONE. OUR REQUIREMENTS

Please be precise with medication.
Please detail exactly the strengths.
Please indicate if you intend to collect your prescriptions from the surgery or the Bourne Pharmacy.
Please ensure that you have included your full name and address and ideally a contact telephone number.

(Note: your repeat prescription will take 2 working days.)

Lower Bourne
TELEPHONE 01252 730100 FAX 01252 730101 RESULTS (12-1pm) 01252 730109 OPENING HOURS 8.30am - 1.00pm 2.00pm - 6.30pm

Farnham Centre for Health
TELEPHONE 01252 730100 OPENING HOURS 8:00AM - 6.30PM