Park Road Surgery - VSM Pharmacy

You have selected PARK ROAD SURGERY

IMPORTANT:

Your prescription will be collected by VSM Pharmacy. It is best to place your repeat prescription’s request at least 5 working days before you run out of medication. This allows time for your GP to authorise the prescription(s) and for our pharmacy team to dispense your medication.

Patient Details
Name*
First Last
Date of Birth*
Contact Details
Phone*
Email
Patient's Doctor*

Please Note: To lessen any delays in processing your prescription please enter into the box below which doctor you usually see regarding this condition or medication, so that the receptionist knows which doctor may be best able to check and sign your prescription.
Medication Information
NOTE: Please enter the drug name(s) and strength(s) as they appear on the drug label or your repeat prescription form. Please do not specify the quantity. Thank you. If you wish to add more items, please click the "+" button on the right of the text field entitled "Name & Strength of Medication".
Name & Strength of Medication:*

Please enter the name & strength of the medication as printed on the dispensing label. Click on the + sign on the right side of the field to add a new medication to your order.
Patient Instructions
Please use the freetext box below for surgery or pharmacy notifications specific to your prescription - e.g. to explain that you are ordering early or need extra quantity because you are going on holiday.
Comment(s)
If you need to order more items than there are lines available, please submit a new form for the additional items. As soon as you press "Submit" below, your prescription request will be e-mailed to VSM Pharmacy and your surgery. Please check your entries above before you proceed. All the information collected through this form is only provided to your surgery and VSM Pharmacy and used to provide the repeat prescription service. This information is not shared with any other third party.
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