Repeat Prescriptions Online Form

Online requests are picked up until 1 pm. (Any request made after this time will be actioned the following working day). Please leave TWO WORKING days between ordering repeat medication and its collection.

Any medication order placed after 1.00pm will be counted as being ordered on the next working day (Monday - Friday) and will be processed accordingly. Medication ordered via the internet after 1.00 pm on Friday will be processed on Monday morning and will therefore be ready for collection on Wednesday.

You may have to come in and see the doctor before the medication is issued, so make sure you order your medication in good time.

Please fill in the form below and use the 'submit' button to send your repeat prescription request to us. ALL FIELDS MARKED WITH AN ASTERISK ARE REQUIRED.

If you require more than ten items then after you have successfully submitted this form, return to this page and submit another prescription request form.

This form is processed via a secure online processor. Once you submit the results you will be requested to validate your submission by entering 4 characters displayed on screen. This prevents spam being submitted via the form. You will also see that the processor uses an https secure server to process the results.

First Name:*

Last Name:*

Post Code:*

Date of Birth (dd/mm/yyyy):*
(eg: 20/02/1971)

Home Telephone:*

Mobile Number:

Email Address:*

Confirm Email Address:*

Medication Name and strength (eg Paracetamol 500mg)

Prescription Request 1:

Prescription Request 2:

Prescription Request 3:

Prescription Request 4:

Prescription Request 5:

Prescription Request 6:

Prescription Request 7:

Prescription Request 8:

Prescription Request 9:

Prescription Request 10:

Where do you routinely collect your prescription: Billingshurst Surgery Lloyds Pharmacy, Billingshurst

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