Repeat Prescription

To request a repeat prescription, please enter your personal details below, followed by the name, strength and quantity of medication you require. Please allow at least 48 hours before visiting your collection point.

We can only process requests for repeat prescriptions – if you require a new medication you will need to book an appointment or speak to one of our doctors on the telephone.

Please select the practice location most relevant to this Online Form submission:

Your Details

Title

First Name

Surname

Date of BirthDD/MM/YYYY

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

Your Address

Address

Post Code

Your Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

Prescription Details

Preferred Collection Point

Comments

Medication Required

Medication 1

Name

Strength

Quantity

Medication 2

Name

Strength

Quantity

Medication 3

Name

Strength

Quantity

Medication 4

Name

Strength

Quantity

Medication 5

Name

Strength

Quantity

Medication 6

Name

Strength

Quantity

Medication 7

Name

Strength

Quantity

Medication 8

Name

Strength

Quantity

Medication 9

Name

Strength

Quantity

Medication 10

Name

Strength

Quantity

Email Confirmation

Tick the box if you would like to receive an e-mail confirming the form has been received by Bartholomew Medical Group.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Main Surgery • Goole Health Centre, Woodland Avenue, Goole, DN14 6RU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.