Order a repeat prescription Surname First names/s Date of Birth NHS number An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website Email address Please provide an email address so we can inform you the status of your request. If you do not have an email please put n/a Medication items Please list the chosen medication which you would like to reorder. We cannot accept requests if you've never had the medication before. Your chosen pharmacy and location Hospital dates If you have recently been in hospital, please include the date you were discharged. Any other comments Yes, I give permission to store and process my data Yes, I understand this form is NOT for urgent medical help Yes, I understand this form is NOT for urgent medical help