Medication Request Form

Use the simple form below to request medication

Please allow 2 working days for us to process and authorise your prescription request. Typically, a pharmacy will need another 2 working days to dispense your medication. So allow 4 working days in total to collect your medication from the date you submit your request.

Repeat Prescription Request

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Prescription Items

Copy exactly the details from a prescription slip you have received from the practice.

Please note that items will only be dispensed if they are included in a prescription from the practice and a medication review is not pending.

Item 1

Item 2

Item 3

Item 4

Item 5

Item 6

Item 7

Item 8

Item 9

Item 10

Special Medication Request

PLEASE NOTE: A clinician may need to speak to you to authorise your special request. Therefore, it is important you supply a valid mobile number and email address. If your request is for repeat antidepressants/anti-anxiety medication it is better to submit an eConsult. Pick ‘I want help for my condition’ –> mental health

Collect from *

Name and address of nominated pharmacy *

Please allow up to 5 days from ordering the prescription to pick up in the pharmacy. If required earlier than this please enter a note in the special request box

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

reCAPTCHA

Prescription Items

Privacy Policy

Local support

Self-help

Services directory

Newburn Health Centre

Subscribe to Practice News