EmailMe Form - Repeat Prescription Online Request

Name *

First Last

*Enter Home address or Pharmacy address where you'd like Prescription sent to. *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Either email or phone number is required for data verification and so that we can contact you; preferably both though!

Phone *

Date of Birth *

DD / MM / YY

Items required *

Please be specific - use your previous medication box information - even better, upload the photo.

File Upload

Upload pictures of medication you'd like - you can upload more than one item description photo.

Terms and conditions *

Agree to terms and conditions

By ticking this box you agree to SurreyGP preparing a repeat prescription for you as requested (where deemed appropriate by the doctor) and that you will settle the repeat prescription fee (£45) by card over the phone when our team calls to arrange collection. If you wish to have the prescription faxed to your local pharmacy an additional fax to pharmacy fee of £15 will be charged. Some requests will require a telephone consultation with the doctor before the prescription can be issued. We will discuss this with you over the phone before preparing the prescription.