Prescription Requests

Patient's Full Name(Required)

First Name Surname

Date of Birth(Required)

Is this prescription for yourself?(Required)

Yes

Your Name(Required)

First Last

Your relation to the Patient(Required)

Email Address(Required)

Mobile Number(Required)

Do you confirm that you've had a prescription with this medication in the last 12 months?(Required)

Yes

Medication Required(Required)

Please list up to 6 repeat prescription medications you require

Medication Name

Quantity

Collection or Delivery(Required)

Please let us know how you wish to receive your prescription

A unique SMS code will be sent to the mobile number you submitted above- this can be taken to any pharmacy to collect your medication (very rarely do pharmacies not accept prescriptions using this code- if however you are having issues collecting your medication please let us know and we will arrange for this to be collected from your chosen pharmacy via another means)

We will notify you when your prescription is ready to be collected

Pharmacierge will be in contact with you directly to arrange a delivery time for your medication. For more information on delivery times and fees please see their website

Please let us know your desired Pharmacierge delivery address(Required)

Street Address Address Line 2 City County Post Code

Any additional information

I confirm I am a registered patient at Courtfield Private Practice(Required)

Yes

Please note:

If any of the information provided on your request is unclear, you may receive a call from one of the doctors to clarify this

We will endeavour to fulfil your prescription request on the same day but always within 24hrs (excluding requests placed on Saturday afternoon/Sunday and bank holidays when we are closed, in which case the prescription request will be fulfilled on the next working day)

There is a fee for controlled drug prescriptions and for any repeat prescription requests where there hasn’t been a medication review by one of the Courtfield doctors in the last year- please see “Our Fees” page for further details