Whitworth Chemists Ltd

Prescription Collection Service Order Form

Repeat Prescription Order Form

To Whitworth Chemists

I confirm that I am giving permission for Whitworth Chemists to collect my repeat prescription from my doctors on my behalf, and that I will advise you if I want to change this arrangement.

Yes
No
*Surname:

*First Name:

*Date of Birth:

NHS Number (If known):

*House Number and Street:

*Town/City:

*Postcode:

*Telephone Number:

*E-mail:

GP:

Please choose your GP's surgery (please select)

*Do you pay for your prescriptions?
Yes
No

If you don't, why are you exempt?
(please select)

*We will require to see proof of your exemption status

Please click the submit button to send the form. You should receive a confirmation e-mail once the form has been successfully submitted. If you do not receive an e-mail receipt, your request has not been successfully transmitted to the pharmacy.

Please remember to order your repeat prescriptions 5 working days before they are due.

Your prescription will be delivered by the Whitworth Chemists driver

Required fields are marked *