Contact Us & Repeat Prescription Service

Complete the form below:

Repeat Prescriptions Form

This service is only available to patients of these surgeries who have a valid, up-to-date, repeat prescription.

Please find below the list of the surgeries we visit for repeat prescriptions.

Select the Relevant Pharmacy:
First Names:
Last Name:
Date of Birth:	(dd/mm/yyyy)
Address:
Phone Number:
Email Address:
Surgery:

Please tell us what medication you require. Be specific and check your spelling. Please take all details from your repeat prescription record slip.

Drug Name	Strength

If you require more than 8 items, please submit another request.

Comments (any comments that you may have about this service)

CONFIDENTIALITY - TERMS AND CONDITIONS
The internet is not secure, and the transmission of data to request medication is entirely at the patient's own risk. The Pharmacy accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above and understand that by ticking this box I give my consent for Eastleigh Pharmacies to order, pick up and dispense this repeat prescription.

Please allow 3 to 4 working days from the time of request to the surgery of your repeat prescription to the time of collection from the pharmacy. This enables us to collect your prescription from the surgery and order any items if necessary before you come to collect. We thank you for your co-operation.