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The Health Centre
Halse Road
Brackley
Northants
NN13 6EJ

Telephone
01280 703460

Fax
01280 840594

Email General Enquiries
(Not medical problems)
 
 

 
 
 
 
Please Note: This form is sent to us via computers that do not belong to the NHS in a non-encrypted format. Complete confidentiality for this type of repeat prescription request can not be guaranteed. If you have an issue with this please feel free to use our normal repeat prescription service.
 
Patients Name*

 
Date of Birth*    
Address    
Contact Tel.*    
Email Address    
Collect prescription from    
   
     
* You must provide this information.
The items requested below MUST be on your regular repeat medication list. 		   
       
 

     Item Description

Dose

  Quantity
       (e.g. Paracetamol) (e.g. 500mg) (e.g. 100)
       
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
       
* please enter the blue 5 letter lowercase word into the box to reduce spam.  
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* Not for medical problems *		    
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