COVID-19 Repeat Prescription Form COVID-19 Repeat Prescription Form Due to COVID-19(Coronavirus) we will be allowing patient to submit more forms online. This is so that we can reduce the number of patients that come down to the surgery. This is so we can reduce your risk of infecting and the risk to others. Please let us know what pharmacy you would like your prescriptions to go to electronically as this will further reduce the need for you to come into the surgery. Please allow 3 working days before collecting your prescription. Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be sent. You can request up to 6 items per form, if you have more than 6 items please complete further form(s). Your Details Surname * First Name(s) * Date of Birth * Patient Number (if applicable) Click here if you don't know your patient number Email Address * Daytime Phone Number Please select which pharmacy to nominate for your prescriptions to go electronically? Concord Pharmacy Sainsbury Pharmacy - Fox Den Road, Stoke Gifford Morisons Pharmacy - Patchway Lloyds Pharmacy - Patchway JHoots - Radcliffe Drive, Stoke Gifford JHoots - Patchway Day Lewis - 508 Filton Avenue, Horfiled Day Lewis - 13 Gloucester Road North Bradley Stoke Pharmacy Boots - The Mall, Cribbs Causeway Boots - Willow Brook Centre, Bradley Stoke Tesco Pharmacy - Willow Brook Centre, Bradley Stoke Click here to see how your printed prescription relates to the form Item E.g Atenolol Strength E.g 50mg NB:If required please type "percentage" not the symbol "%". Amount E.g 25 tabs Item Strength Amount Item Strength Amount Item Strength Amount Item Strength Amount Item Strength Amount Item Strength Amount I agree to the Terms & Conditions * Yes reCAPTCHA Submit If you are human, leave this field blank.