Maryhill Practice - Prescription Order Form

Fields marked with a * are required

Name *

Date Of Birth *

Email Address

Drug Name	Strength

If you wish to collect your prescription from the chemist please specify which chemist
(eg. Glassgreen(Boots) / Boots(High Street) / Bishopmill / Loyds / Hopeman / Westend / Lossie / Lhanbryde / Loyds(Lossie) / Springfield(Boots))

Any Additional Comments

Please allow 48 hours for prescriptions to be processed before collection.
Prescriptions received on a Friday will not be ready until the following Tuesday afternoon.

Details are only remembered for the currently logged on Windows user account. To save more than one set of details you must create new Windows User Accounts.
Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of ordering a repeat prescription.
Note that this form is delivered over an encrypted link to our server. If your browser does not indicate this, it is because your practice has chosen to display this form within a frame. You may still view the cetificate by right-clicking and choosing Properties.