Repeat Prescription

Our preferred pathway for you to request repeat medication is via the NHS APP or systmonline.

We are able to respond more quickly to requests submitted by this route.

The request form below should only be used if you are unable to use preferred online services as indicated above.

Using this form may result in delays to your request and we would urge you to use the NHS app

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 5 working days before visiting your collection point.

We can only process requests for repeat prescriptions – if you require a new medication you will need to call our reception team to book a telephone call.

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

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

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 Emsworth Medical Practice • North Street, Emsworth, Hampshire, PO10 7DD.

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.