Repeat Prescription Service signup form

Your personal details

First Name

Last Name

Date of Birth*

Telephone no

Mobile No

E-mail address

Your address

Address

City

Postcode

Your Doctors surgery details

Select Area*

Grangetown Llandaff Pontnewydd (Pontypool) Taffs Well Whitchurch

Doctors Surgery Name

Medication required

Please enter your medications exactly as they appear on your surgery re-ordering form.
The items requested MUST be on your regular repeat medication list.

Prescription example

Drug Name & Strength*

Paracetamol 500mg (example)

Directions

Two, four times a day (example)

Quantity

100 (example)

Drug Name & Strength

Directions

Quantity

A maximum of 20 items allowed.

Additional comments

Collection/Delivery

Would you like your prescription delivered?*

No thanks, I'll collect it from the pharmacy Yes please, I would like them delivered

Preferred Health Plus Pharmacy for collection*

Grangetown (Bishop St), Cardiff

Grangetown (Clare Rd), Cardiff

Llandaff, Cardiff

Taff's Well, Cardiff

Whitchurch (Merthyr Rd), Cardiff

Whitchurch (Park Rd), Cardiff

Pontnewynydd, Pontypool

Collection start date

Preferred Delivery Time^*

Afternoon12pm - 5pm Evening5pm - 8pm

Delivery start date

We only deliver from Monday - Friday

Advised consent

I authorise Health Plus Pharmacy to collect my prescription and supply my medication

I agree to the Health Plus Pharmacy terms & conditions

Sign up to our Mailing List

I would like to receive communication updates on products, special offers and exclusive discounts from Health Plus Pharmacy.

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Repeat Prescription Registration