Acute Prescriptions - Memorial Medical Centre

This service will be on a pilot basis and we will review this in 3 months. Please allow three full working days (72 hours) for acute prescriptions to be processed. Remember to take weekends and bank holidays into account. Remember the details you submit will be sent to us by unencrypted email via the Internet. This means that complete confidentiality is not possible because we cannot guarantee the security of the Internet. If you are not comfortable with this arrangement you may prefer to order your prescription in person, or by post.

Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be sent.
Name*
First Last
Date of birth*
Date Format: DD slash MM slash YYYY
Email address*
Enter Email Confirm Email
Daytime telephone number*
You can add up to 12 items on this form. As you type in each item another set of boxes will appear.
Item 1 - eg Atenolol*
Strength 1 - eg 50mg
Quantity 1 - eg 28 tabs*
Item 2
Strength 2
Quantity 2
Item 3
Strength 3
Quantity 3
Item 4
Strength 4
Quantity 4
Item 5
Strength 5
Quantity 5
Item 6
Strength 6
Quantity 6
Item 7
Strength 7
Quantity 7
Item 8
Strength 8
Quantity 8
Item 9
Strength 9
Quantity 9
Item 10
Strength 10
Quantity 10
Item 11
Strength 11
Quantity 11
Item 12
Quantity 12
Strength 12
Pharmacy or GP Surgery collection?*
- Collect from Pharmacy
- Collect from GP Surgery
Preferred Pharmacy
Additional info e.g. extra medication needed as going away