Please Note: This form is sent to us via computers that do not belong to the NHS in a non-encrypted format. Complete confidentiality for this type of repeat prescription request can not be guaranteed. Please feel free to use our normal repeat prescription service.
Patients Name *
Date of Birth *
Address
Contact Tel.*
Your Doctor	Select your usual Doctor Dr Graham Hagan Dr Anu Rao Dr Andrew Taylor Dr Rita Codlin Dr Andrew Reed Dr Lisa Scobbie Dr Rebecca Cusworth
Collect from*	Select where you will collect from Lenham Surgery Harrietsham Surgery Saxon Warrior Chemist
* You must provide this information. The items requested below MUST be on your regular repeat medication list.
	Item Description	Dose	Quantity
	(e.g. Paracetamol)	(e.g. 500mg)	(e.g. 100)
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
	*Please type the blue word into the box below (to help us reduce spam email)
	Not for medical problems
Comments about this Prescription

Please allow 2 full working days for us to process your request. For those patients whom we dispense for, your items will be ready within 4 working days.
(We can only post your prescription to you if you provide us with a
Stamped addressed envelope)