some text
Was the prescription issued by a UK registered doctor?
Doctor Name:*
Doctors Address:*
Doctors Tel:*
Do any of the items on the prescription appear on the restricted list?
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Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
Product Name Here
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Do any of the items on the prescription appear on the restricted list?
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.