Prescription order form

Please only order the item(s) you require. We need the name of the drug, the dosage, and how many you need per item. Prescriptions will be ready for collection 48 working hours after ordering.

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Which surgery are you registered with? *

• Miriam Medical Centre
• Earlston & Seabank Medical Centre

Name *

First

Last

Date of birth *

Phone number *

This is in case we need to contact you about your prescription.

Item(s) required *

Please only order the item(s) you require. We require the name of the drug, the dosage, and how many you need.

Where should we send your prescription? *

• My usual nominated pharmacy
• A different nominated pharmacy

Which pharmacy should we send your prescription to? *

Please provide the name of the pharmacy and its location.

Submit prescription request