Repeat Medication Request Form – Bruntsfield Medical Practice

Please allow for a full 4 working days for your prescription to be processed by the Practice and your Pharmacy.

Be aware that turnaround time will be longer around the time of any public holiday where the Practice is closed. Please take that into consideration when ordering your medications and give yourself enough time.

Repeat Request

Your Name

Date of Birth

Email address

Please give all drug names you require, in full. You should only use this form if you are requesting medicines that are on your repeat medication re-order form (on the counterfoil of your last prescription). If you need something that is not on this form you will need to speak to your usual GP.

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

Drug Name

Strength (e.g. 20mg)

Quantity (if known)

0 of 350 max characters

I will collect my prescription from:

My Usual GP:

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