Please note that we ONLY accept orders for repeat prescriptions when they are received on this form. We do NOT accept Repeat Prescription requests by email in any other format and any received will be ignored. All the information you need to complete this online form can be found on the paper Repeat Prescription form issued to you by your Doctor. It is important that we receive a fully completed online form containing the correct data otherwise a Repeat Prescription cannot be issued. We can only accept Repeat Prescription requests for items listed on your paper Repeat Prescription form, unauthorised items cannot be dispensed.      If you want information about your prescription, Click Help for a new window to open with information. If you would like this form to retain previously entered information you will need to ensure that your browser preferences are set to enable the use of cookies and javascript.
NOTE: Please add NoReply@qpmc.org.uk to your anti-spam lists otherwise you may not receive the confirmation message. Some providers block emails that are repeated. If you order the same prescription each month and sometimes not get a confirmation, it may be because your email provider has seen a similar email sent multiple times and blocked it. Please ensure your spam settings allow the address: NoReply@qpmc.org.uk
Patient Name:
Address:
Date Of Birth:	(DD/MM/YYYY)
Telephone:
Email Address:
Doctor:	Please check that you have the correct doctor selected Dr Craven & Dr Waddle Dr Hulyer & Dr Finnie Dr Saha/Dr. Rahman & Dr Burrows Dr Kirkbride & Dr Hazelton Dr Hall & Dr Rashid
	Item Description	Dose	Strength
Example Item
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Item 2:
Item 3:
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Item 9:
Additional Information:
A 'confirmation of receipt' email will be sent to you so that you know your Repeat Prescription request has been sent to us. Please allow two working days for your prescription to be prepared from the date of the confirmation email. Collect your prescription from your usual delivery location.