Name

	*Compulsory Fields
*Surname:
*E-mail:
*Date of birth: (dd/mm/yyyy)

*Patient No:	This number is at the top right hand corner of your repeat request form

Collection:	Please indicate if we normally send your written prescription direct to Carson's Chemists

	NB The Medicine and Strength fields must match your prescription EXACTLY. Move from field to field using the mouse orTab key. DO NOT use Enter
	Medicine	Strength
*Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
Prescription 7
Prescription 8

Comments/ Additional Information

	If your prescription request arrives before 9am Monday to Friday, it will normally be ready to collect after 3pm the next working day. No e-mail prescriptions will be processed on Saturday.

	The administration office which receives this e-mail will only deal with prescription requests. For any other request, please call the Health Centre on 0118 972 2188.