Repeat Script / Referral

By using this service, you agree to the terms and conditions below:
1. The doctor has the right to not fulfil the request - in which case the applicant will be notified by return email
2. Two full working days will be required between submission of the request and its collection.
3. Prescriptions and referrals are to be collected from St Agnes Surgery.
4. Only the doctors listed on the form will provide this service to their own patients.
5. It is practice policy that repeat scripts and re-referrals are issued without a consultation only by prior agreement with your Doctor.
6. This service will not send your data encrypted and is therefore not impervious to data hijack.
7. The Practice, nor its doctors, accept any liability or responsibility should any part of the process fail.
8. A fee of $5 for a repeat prescription and $2 for a specialist re-referral applies.

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Select what you require from the dropdown list *

Select your Doctor from the dropdown list *

Other Comments *

REPEAT MEDICATIONS

Medication1 *

Strength1 *

Medication2 *

Strength2 *

Medication3 *

Strength3 *

SPECIALIST RE-REFERRAL

Specialist's Name *

Specialty e.g. Cardiologist *

Name of who this script/referral is for if not yourself *

Condition re-referral is required for: *

Submit

St. Agnes Surgery

REPEAT PRESCRIPTION / REFERRAL REQUEST

REPEAT MEDICATIONS

SPECIALIST RE-REFERRAL