some text
Was the prescription issued by a UK registered doctor?
Yes
No
Doctor Name:
*
Doctors Address:
*
Doctors Tel:
*
Do any of the items on the prescription appear on the restricted list?
Yes
No
Restricted Products
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Product Name Goes Here
Do any of the items on the prescription appear on the restricted list?
Yes
No
Don't Know
If you would like us to retain your prescription in our pharmacy we can do so and prompt you when your next repeat can be dispensed.
