Repeat Prescription Request Form

Cross Deep Surgery  

020 8892 8124

2-4 Cross Deep   London   TW1 4QP

PLEASE NOTE: ALL PRESCRIPTIONS TAKE A MINIMUM OF 72 HOURS NOTICE. 

The way you order your repeat prescriptions online is changing. 

You need to register for our new online services. When you are next in the surgery, please complete an online services registration form. To learn more about these new services available to you, visit the Online Services page on our website.

By registering for our new Online Services you will also be able to book, change and cancel appointments online. 

Have your contact details changed? Need to update your medical record? 
Let us know using our online forms.
Click here to notify us of a change of contact details
Click here to update your medical record

Important Information

Saving details help

You do NOT have to register to order your repeat prescription - it is your choice.
If you do not wish to register simply use the form below to place your order.

There are some advantages to registering and you can read about them here. To register click the link above.

Choose a Patient

This form can remember details for up to two people - you must register to store more

Patient Details

Medication

You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time.
Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
Drug Quantity and/or Strength
e.g. 1mg once a day
Required
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Comments

Please do not include medical problems here - these should be discussed with your doctor

Sending Your Request



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About This Form

Fields marked with a red asterisk are
compulsory.

This form uses cookies to store your information for next time.

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, register with the prescription 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

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.