Prescription Request

Step 1 of 3

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, 500mg
Name 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
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 pharmacy
Please 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.
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