NHS Repeat Prescription Form 1 Terms & Conditions2 Your Details3 Prescription Items4 Payment Terms & ConditionsYou can request a repeat prescription by completing and submitting an online form. First you will need to read and accept our terms and conditions: 1. The service is provided only to request repeat prescriptions. 2. You can order items listed on the repeat request form attached to your last prescription. 3. If the date for your next review with a doctor has passed you may be asked to make an appointment before they will issue a repeat prescription. 4. Your prescription will be delivered approximately three working days after your request has been submitted. 5. An email confirming your repeat request will be sent to the address you provide on the form on the following page. Please tick the box below if you agree* I confirm that I have read and accepted the terms and conditions above. Getting started is simple, you just need to tell us the details of the items that you would like to order from your NHS prescription, and give us some simple registration details. We will then request your prescription from your GP. Once we have obtained your prescription we will dispense and deliver it directly to you for FREE. NHS Prescription charges are standard at £9.15 per item unless you are exempt from payment. Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be accepted. Name First Last Email (to receive confirmation of your request)* Enter Email Confirm Email Phone Number*Address* Street Address Address Line 2 City ZIP / Postal Code Date of Birth* GP DetailsGP's Name*GP's Address* Street Address City ZIP / Postal Code GP's Phone Number* Prescription Items*Description (eg Atenolol)Strength (eg 50mg)Quantity (eg 28 Tabs) Additional InformationPlease list any other medicines below. Prescription ChargesDo you Pay for Prescription Charges?* Yes No, I have an exemption Your Payment Exemption Status*Select your payment exemption statusYou are under 16 years of ageYou are 16, 17 or 18 and in full-time educationYou are 60 years of age or overYou have a valid maternity exemption certificateYou have a valid medical exemption certificateYou have a valid prescription pre-payment certificateYou have a valid War Pension exemption certificateYou are named on a current HC2 charges certificateYou are prescribed free-of-charge contraceptivesYou get Income Support or income-related Employment and Support AllowanceYou get Income based Jobseeker's AllowanceYou are entitled to, or named on, a valid NHS Tax Credit Exemption CertificateYou have a partner who gets Pension Credit Guarantee Credit (PCGC)How would you like to pay for your prescription?*Pay onlinePay on DeliveryPatient Consent*Prescription collection and delivery service required. I authorise 'Five Ways Pharmacy' to collect my prescription from my surgery named above. Electronic prescription receipt and delivery required. Patients Signature - Please tick this box to act as your signature.* Please enter today's date* Prescription fee Price: £ 9.35 Quantity: Total £ 0.00 This iframe contains the logic required to handle Ajax powered Gravity Forms.