Grosvenor Road Surgery....Online
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Request Prescription

Please note: It is important that you read our terms and conditions before using this service.

Please fill in your details and click the 'Request' button at the bottom of the form. Your request will then be sent to us. Please allow two working days before collecting your prescription.

Please fill in ALL fields
Use your TAB button, or your mouse to move from one field to the next. Pressing enter to go to the next field will click the request button and you will be taken to an error page.
You must be a registered patient to use this service.
You must click the tick box to accept our terms and conditions of service.

First Name

Surname

Date of Birth                                        Phone Number
                    
Your Doctor

E-mail Address



*Please tell us the drugs you require. Be specific and check your spelling. If you are unsure of the drug, please type the name that is shown on the box.

Drug Name*                                                                     Strength
    
    
    
    
    
    

Collection Point

Comments (or extra medication)


I accept the terms & conditions

                                 
 

 
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