The Wiggly Demo Surgery -

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Repeat Prescription Requests

Your patients can use this page to request their repeat prescriptions.

You can enter text above and below the form. You can use these areas to display your practice policy for dealing with prescriptions. How long should your patients wait before collecting their medication? Do you want them to enter the strength and dose of each medication?

Add the collection points available for your patients to use, they will appear in the drop down list on the form.

* - fields required

Forename: *
Middle Name:
Surname: *
Date of Birth: Format: dd/mm/yyyy *
House name/number: *
Street:
Town: *
City:
County:
Postcode: *
Telephone: *
Mobile Number:
Email: *
Repeat Email: *

Medication 1:*

Strength:

Dose:

Medication 2:

Strength:

Dose:

Medication 3:

Strength:

Dose:

Medication 4:

Strength:

Dose:

Medication 5:

Strength:

Dose:

Medication 6:

Strength:

Dose:

If you require more than 6 items please click here

Medication 7:

Strength:

Dose:

Medication 8:

Strength:

Dose:

Medication 9:

Strength:

Dose:

Medication 10:

Strength:

Dose:

Medication 11:

Strength:

Dose:

Medication 12:

Strength:

Dose:

If you require more items please click here

Additional notes:

Pick up: *

Code:

Enter the characters as seen on the image above (case insensitive):

Save my details for next visit
Please e-mail me a copy of my request

The completed requests will be sent to an e-mail address of your choosing.

However, if you use our EnCompass Messaging System then the prescription requests can be sent directly to a designated pool. This will give you the ability to redirect the request to a GP if necessary for authorisation and with one click you can inform the patient that the prescription has been issued.

GP Website from Wiggly-Amps Ltd.