Prescription order form

Please only order the item(s) you require. We need the name of the drug, the dosage, and how many you need per item. Prescriptions will be ready for collection 48 working hours after ordering. We recommend using the NHS App to order your medication.

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Which surgery are you registered with? *

• Miriam Medical Centre
• Earlston & Seabank Medical Centre

Name *

First

Last

Date of birth *

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Phone number *

This is in case we need to contact you about your prescription.

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Item(s) required

If you wish to add more items, use the + icon at the end of the row.

Drug name and dosage *

i.e. Citalopram 20mg

Amount *

i.e. 28 capsules

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Where should we send your prescription? *

• My usual nominated pharmacy
• A different nominated pharmacy

Which pharmacy should we send your prescription to? *

Please provide the name of the pharmacy and its location.

Submit request