Prescription Order Form (PAGE)

Prescriptions

Prescription Order Form

Prescription Order Form

Prescription Request Form

Please complete the online form to request a repeat prescription.

“*” indicates required fields

First Name*

Surname*

Date of Birth*

Day

Month

Year

Address*

Street Address Address Line 2 Post Code

Phone*

Enter Email Optional Confirm Email Optional

Please select one of the following regarding your smoking status*

Never Smoked

Current Smoker

Ex Smoker

User of Electronic Cigarette

I do not want to give this information

Please select one of the following regarding your alcohol consumption*

I do not drink alcohol

I only ever drink occasionally

Light drinker (1-2 units per day)

Moderate drinker (3-6 units per day)

Heavy drinker (7-9 units per day)

I do not want to give this information

How tall are you? Optional

How much do you weigh? Optional

What is your blood pressure? Optional

If you do not know this information, then please call into the surgery and use our free BP machine located in reception. This will also record your height and weight. Just ask reception for a gold token.

Enter each medication and strength on your prescription*

Medication

Strength

Dose

Please use the + icon to add more that one medication

Which Pharmacy would you like your prescription to be sent to electronically?*

Additional notes: Optional

Consent*

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

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with The Beeches Medical Centre, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS Please read our privacy policy to discover how we protect and manage your submitted data.

The Beeches Medical Centre

20 Ditchfield Road,
Widnes,
Cheshire,
WA8 8QS

Get Directions

0151 424 3101 / 0151 244 3339

HCCG.Beechesmc@nhs.net

Mo,Tu,We,Th,Fr 8:00 am to 6:30 pm

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