Online repeat prescription form Submit your prescription form online to order your repeat medication using the form below. First name(s) Please enter your first name in the field below Surname Please enter your surname in the field below Your date of birth Please enter your full date of birth in the field below Your telephone number Please enter your telephone number in the field below Your email address Please enter your email address in the field below NHS number (if known) Your NHS number is a 10-digit number that you can find on any letter that the NHS has sent you. For example, 458 777 3456. Providing your NHS number helps us to make sure we safely match your records from the NHS. Medication request Please enter the name of medication required, its strength and the amount (where relevant). You can enter as many items as needed.