Medication Not on Repeat Online Form

Form Completion

One form submission for each medication required

Please remember that it can take up to 48 hours, or 2 working days for the Practice to process your request; thereafter it can take another day for the Pharmacy to process.

Medication Not on Repeat

This form is to be completed for any medication that is not on your Repeat Prescription

Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email
Telephone contact number*
Please let us know your main telephone contact number
When not to call*
Please let us know when we cannot call you. We cannot guarantee when we can call you. Enter N/A if we can call you at any time
Medication Name*
It is more helpful if the name is copied from the original packaging
Dosage*
Enter the dosage of the medication
How often taken*
How often do you take the medication
Prescriber*
Who prescribed the medication and when?
Reason*
Reason that the medication is taken
Date of last medication*
Date the last medication was prescribed
Date Format: DD slash MM slash YYYY
Additional Information
Please provide any additional medication that will help the Pharmacist, GP, or Prescribing Nurse with your request
CAPTCHA
Consent*
I agree to the privacy policy.
Signature*

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Medication Not on Repeat order form

Update your Details

Name*
Prefix First Middle Last
Date of Birth*

DD
MM
YYYY
Gender*
- Male
- Female
Marital Status
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Landline Phone Contact Number
Mobile Phone Contact Number
Additional family members
Please provide age, gender, names, and anything else that will help us to help you
Anything else
Anything else that we need to know about e.g. when not to call, special circumstances etc
Patient-Services
Are you interested in signing up for Patient-Services which will allow you to request your medications online, book medical appointments, and see areas of your medical records?
- Yes
- No
Consent*
We keep personal information as set out in the Scottish Government Records Management: NHS Code of Practice (Scotland) Version 2.1 January 2012 (the code). The code sets out the length of time we need to retain information (called ‘minimum retention periods’) including personal information, held in different types of records like personal health records and administrative records.

We maintain a ‘retention schedule’, as directed by the code, which details the minimum retention period for the personal information we use and how we safely dispose of it.
I agree to the privacy policy.
Signature*

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Monday
07:30 - 18:00
Tuesday
08:00 - 18:00
Wednesday
08:00 - 18:00
Thursday
08:00 - 18:00
Friday
08:00 - 18:00
Saturday
CLOSED
Sunday
CLOSED

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