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Shakespeare Surgery
Worsley Mesnes
Health Centre
Poolstock Lane
Wigan
WN3 5HL

Tel: 01942 481531
Fax: 01942 481543
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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.
 
Patients Name *  
Date of Birth *    
Address    
Contact Tel.*    
Email Address    
Collection

 
Please collect from Surgery if prescription is urgent		  
* You must provide this information.

The items requested below MUST be on your regular repeat medication list.

If you have more than 8 items please send a second e-mail adding the additional items to this second message.
 

  
 

     Item Description

Dose

  Quantity
       (e.g. Paracetamol) (e.g. 500mg) (e.g. 100)
       
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
   
* Not for medical problems *		    
Comments about this Prescription or additional collection messages

 

                          

 
 
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