• First names
• Last name
• Date of birth
  (dd/mm/yyyy)

Please tell us the medication you require:

If you require more than three items, please submit another request.

• Collection point

Please tell us whether you want to collect your prescription from Richmond Practice or a local pharmacy (Please state which Pharmacy by name).
Please note: If you would like to collect your prescription from a local chemist you will first need to confirm the arrangement with the pharmacist.

• Comments

Repeat prescription request charge: £15