40 Oxford Street, Leamington Spa, CV32 4RA

Please use the below form to order repeat prescriptions.

Repeat Prescription

If you are not registered for our secure online patient access system you can use the secure web form below to order your repeat medication.

Please take care to complete the form accurately to order a repeat prescription from the surgery.
Any field marked with * is mandatory

Your Details

Title
First Name*
Surname*
Date of Birth

Contact details

Email Address*
Home Phone Number
Mobile Phone Number

Prescription Details

GP Name
Preferred Collection Point
Comments

Medication Required

Medication 1 Name
Medication 1 Strength
Medication 1 Quantity

Medication 2 Name
Medication 2 Strength
Medication 2 Quantity

Medication 3 Name
Medication 3 Strength
Medication 3 Quantity

Medication 4 Name
Medication 4 Strength
Medication 4 Quantity

Medication 5 Name
Medication 5 Strength
Medication 5 Quantity

Disclaimer

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and SSL (using a 64 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted using DES Encryption paired with RSA Encryption, secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

I confirm I have read the disclaimer above and wish to submit this online form to The Forum Health Centre*

Security

Please leave this next field blank to prove you are a person and not a spam robot.

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