REPEAT PRESCRIPTION FORM

Prescription Request

The Tyburn Private Medical Practice will review your prescription request on the same working day and endeavour to have your prescription sent out within 24 to 48 hours. We will try to expedite this if it is required urgently.

Please note that for repeat prescriptions, certain medications will require a medical review within a stated period before they can re-issued. It is a company policy that we will always follow current prescribing regulations and guidance set by the General Medical Council (GMC) and adhere to best evidence-based medical practice.

Charges

The Tyburn Private Medical Practice do not charge for our repeat prescriptions service.

Patient Info

First Name *

Last Name *

Date of Birth *

Email *

Medication

Drug 1:

Dosage 1:

Amount 1:

Drug 2:

Dosage 2:

Amount 2:

Drug 3:

Dosage 3:

Amount 3:

Drug 4:

Dosage 4:

Amount 4:

Drug 5:

Dosage 5:

Amount 5:

Any further medication required?

Delivery

Delivery method *

Privacy Protection: Information submitted is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted. All information submitted is accessed over a secure connection by a nominated Practice staff member. Our practice has a strict confidentiality policy. This information is not shared with any third-party organisations. This information is retained for up to 28 days. I consent to my information being used for the purposes described above and wish to submit this online form to The Tyburn Private Medical Practice. *