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collinsmedicalpractice@gmail.com
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Prescriptions
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Prescriptions
You can use the form below to order your repeat Prescription with us. Please allow 48 hours for prescriptions to be processed. All prescriptions must be collected from the surgery.
1
Personal Details
2
Medicine Details
3
Delivery & Notes
Personal Details
Please fill out the following information with as much detail as possible so we can properly identify you..
First Name
Last Name
Phone Number
Email
Prescription Details
Please let us know exactly which medicines you require and the length of each medicine's prescription..
Number of Medicines
One
More than One
Medicine Name
Prescription Duration
1 Month
3 Months
6 Months
Medicine Names and Durations
Please list below the medicines you require and the prescription duration for each. Use a separate line for each one.
Additional Information
Any additional information you think we might require to process your request..
Additional Notes
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