Prescriptions – Cholmley Gardens Medical Centre

Repeat Prescription Form

Please allow up to 2 working days before collection, thank you

First Name *

Last Name *

Date of Birth *//

Address *

Mobile Number *

Home Telephone

Medication Required *

For clinical safety purposes we require the names of your medication. Your request may be rejected if you input "my diabetes medication"

Nominated Pharmacy *

The Cholmley Gardens Medical Practice can send your medication electronically to a nominated pharmacy of your choice to be ready for collection

Nominated Pharmacy [Other]

Message for GP (if required)

Name