Patient Services Form - Online Request Form

This service provides quick and easy access to your current repeat prescription list and links directly to your medical records—meaning there's no need to manually enter medication names. It's simple, convenient, and keeps your prescriptions up to date.

Manage Your Healthcare Online: Order prescriptions at your convenience.

Registration Process:

1. Complete and submit this form.

2. Check your email: One of our team will send a confirmation email in due course (check junk folder).

3. VITAL FOR ACCOUNT SET UP: FOLLOW THE INSTRUCTIONS IN THE EMAIL TO SETUP YOUR ACCOUNT.

Eligibility Criteria:

Patients aged 16 and over: Must possess an individual email address to comply with GDPR regulations.
Parents registering children aged 12-15: If the child is capable of making their own decisions, they must have an individual email address. For younger children or those not deemed capable, a parent/carer email may be used.

Online Request Form

Name *

Date of Birth *

Phone Number *

Email Address *

Address *

Postcode *

Preferred Pharmacy pickup *

I understand that It is my responsibility to keep my account secure by keeping my details confidential. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I would like to consent to receive SMS messages from the practice.

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 18 June 2026
Page created: 15 October 2026

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Patient Services Form - Online Request Form

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