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. If you have an issue with this please feel free to use our normal repeat prescription service. Name: Address: Date of Birth: Contact Number: (the telephone number we can contact you on during office hours) Email Address: Medication required: Please enter exactly as it appears on your repeat prescription order slip. Preferred collection point: Surgery  Owen Jones  Boots