Prescription Request Form - Bro Pedr Medical Group

Please only use this form to request authorised repeat or 'one-off medications' you have been prescribed before and/or hospital recommendations.

Your request will be subject to a doctor's evaluation and/or hospital documentation.
You may require an appointment or telephone consultation before we can authorise and prescribe your request.
You can request up to five items using this form.
Your prescription will be sent to your nominated destination for collection unless another destination is specified by you.
We will only contact patients, where there is a query on the request.

Name

Date Of Birth

Address

Telephone Number

Email Address

Please list your request below ensuring you complete all fields. You can request up to five items using this form.

Is this request for repeat medication that you take regularly, or acute medication you may have been prescribed previously?