Acute Prescriptions Please note, this form should be used for requesting acute medication only. Repeat prescriptions can be ordered via patient access by clicking here. Any requests received for repeat prescriptions will be rejected. Order Acute Medication 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 50mgQuantity 1 - eg 28 tabs*Item 2Strength 2Quantity 2Item 3Strength 3Quantity 3Item 4Strength 4Quantity 4Item 5Strength 5Quantity 5Item 6Strength 6Quantity 6Item 7Strength 7Quantity 7Item 8Strength 8Quantity 8Item 9Strength 9Quantity 9Item 10Strength 10Quantity 10Item 11Strength 11Quantity 11Item 12Quantity 12Strength 12Pharmacy or GP Surgery collection?* Collect from Pharmacy Collect from GP Surgery Preferred PharmacyAdditional info e.g. extra medication needed as going away