Please enter your data in step by step
SURNAME		FIRST NAME		DATE OF BIRTH

To receive email confirmation please enter your email address AND tick the yes button otherwise leave both boxes empty.	yes
Please enter your repeat prescription requests by each individual drug.If you have more than 8 drugs to request you will need to submit this form twice.
drug 1. drug 2. drug 3. drug 4. drug 5. drug 6. drug 7. drug 8.
If you wish to choose a chemist check the appropriate button otherwise leave blank Boots  Helms  Manor Nottingham Rd   Manor Kirk Hallam  Manor Bath St   Williams
If you would like to help us keep your clinical records up to date please answer the following question otherwise please leave blank. Never smoked  Currently non smoking  Current smoker
7.Please press the click button and then be prepared to wait a few seconds.A message will then come up saying you have successfully submitted your requests