Prescription Request Step 1 of 3 33% Surname* Forename* Date of Birth* MM slash DD slash YYYY Telephone*LGP Doctor (If known) Please advise if there is specific symptoms or reason for the request Medication(s) requested:Name and dosage i.e.: Paracetamol, 500mgName of Drug* Strength* Dose schedule* Frequency* Supply amount* Date Last Prescribed* MM slash DD slash YYYY Medication Collection/Delivery:*How you would like to receive your prescription (please complete)* Posted to my home address Collect from LGP Fax directly to a pharmacy Please arrange for Pharmacierge to contact me Posted to my home address*Please advise Home address Street Address Address Line 2 City ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Collect from LGP ( You will be requested to provide ID on collection)If you have nominated a friend or family member to collect the script on your behalf, please advise their name Fax directly to a pharmacyPlease state the name and fax number of the pharmacy. If there are a few pharmacies of the same name i.e. Boots, please state which branch you want it sent to. Pharmacy Name: Pharmacy Fax Number: Pharmacy Address: Telephone: We how have free prescription delivery service available, enabling your medication to be delivered directly to you. We simply provide your prescription and contact details to Pharmacierge (the pharmacy concierge service) and they will contact you to arrange your free delivery and take payment for the medication. For all London postcodes delivery is made in 2-4 hours and for all other UK postcodes delivery is overnight. If this service is something you would like to use please do let us know and we will organise it for you. Please note: Prescription requests are only actioned on business days Please ensure you have a form of Identification on you when collecting scripts Repeat prescription charges are £37 unless you are an annual prescription member Requests over the weekend or on bank holidays will be processed on the next working day Requests for Controlled Drugs will be assessed on case by case basis and are only available for collection between 08:30 – 17:30 Monday – Friday (excluding bank holidays) by the named recipient. CAPTCHA