About This Form
Fields marked with a red asterisk are
The information is stored on your computer when you send your request or when you
switch patients - but only if you check the 'Remember my details...' box.
To save details for a second person use the radio buttons at the top of the
form. To save details for more than two people or if you are having trouble with
cookies, use the alternative service and your details will be
saved securely in the online database and recalled when you log in. Registering
is quick, simple and free.
Personal information retained on this system is stored in a secure data centre located
in the UK and is treated as confidential. Where appropriate this data is deleted
two months after its creation.
By using this form you will be sending information about yourself across the Internet.
Whilst every effort is made to keep this information secure, you should be aware
that we cannot offer any guarantees of absolute privacy. If this matter concerns
you then you should use another method of ordering a repeat prescription.