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On-line Prescription Request
     
 
   
ON-LINE PRESCRIPTION REQUEST
   
Important Information - Please Read

Dispensary telephone number is 01458 253253

Completed prescriptions will be available for collection from the 2nd working day after the date of processing (i.e. 48 hours).

e-form requests (below) received after 5:30pm will not be activated until the following working day.

Patients should complete a consent form before they can obtain their medication at their chosen destination.

If your prescription is collected by a chemist please allow more than 48 hours before collecting from the chemist in order to ensure your medication is in stock.

PLEASE READ

To use this system, you will have to enter information about yourself that will be sent to us across the internet.

This e-form information is not encrypted, but will be no less secure than a normal email.

We can not guarantee that this information will not be seen by others.

AUTO-COMPLETE

You can use your browser's AutoComplete function to help complete your form. Once set-up AutoComplete can remember details you have entered in the past.

Click here
(Word Document) or here (pdf Document) for set-up instructions. If you do not have Word or Adobe Acrobat click here to download the latest version of Adobe Acrobat.

Your personal details
Your Doctor
Patient Number (if known)
Full Name Enter Name
Address Enter Address
Post Code Enter Postcode
Date of Birth Enter DOB
Other contact details
E-mail address Enter EmailInvalid format
Home telephone no. Enter Telephone
Other / Mobile

 

Prescription requests
Item 1 Strength Qty
Item 2 Strength Qty
Item 3 Strength Qty
Item 4 Strength Qty
Item 5 Strength Qty
Item 6 Strength Qty
Item 7 Strength Qty
Item 8 Strength Qty
 
Additional information

 

Collection
I will collect from:
Acceptance
Please confirm your acceptance of Langport Surgery’s information for online repeat prescriptions (as shown above) by inserting your name in the box below.

Accepted by

Enter Name

  Your Full Name is missing
Your Address is missing

Your Postcode is missing

Your Date of Birth is missing

Your Email Address is missing

Your Email Address format is invalid

Your Home Telephone is missing

Your 'Accepted By' name is missing
 
 

   
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