Prescription question

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Named GP (if known):

What is your prescription question?

I confirm that my enquiry is not urgent, and it may take up to 2 working days before I receive a reply.

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