Millhouse Medical Centre Prescription Request Form


Have you seen a doctor or visited the hospital recently? Yes No

First Name
Surname
Address
Phone *
Email *

Doctor Name


Do you wish the script to be sent direct to your pharmacy? Yes No
Enter pharmacy details below (if collecting script, please leave blank)

Cost is 24.00 per script, 27.00 if faxed to pharmacy.


Pharmacy Name
Pharmacy Address

or Fax Number

This service is provided for our registered patients. 24 hours notice is required for repeat prescriptions; after this time prescription may be collected from MIMC 128 Reception, unless it has been faxed direct to chemist. A nurse or doctor will phone if there are any problems with this request. Please Note that all patients requesting medication must be seen in person at LEAST once a year.

Please list
            medications

Don't Forget to press SUBMIT