- McPherson Pharmacy

Private Prescription Request

Note: * indicates required information.

Patient Details

Tell us your details first

Full Name*

Address*

Street Address City ZIP / Postal Code

Date of Birth*

DD slash MM slash YYYY

Preferred Contact Method*

Phone

Mobile

Email*

Phone*

Mobile*

Do you require your medication to be posted?*

You have the option of having your medicines delivered, either to your home or to any other address in the UK. Your prescription will be delivered by Royal Mail, parcel recorded service. You must be present in person to take delivery of your medicines and you may be asked for photo ID. Our delivery charge is that of standard post office fees, £3.90 for 2nd class and £4.40 for 1st class, please advise if you wish 1st or 2nd option.

Prescriber Details

Full Name*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Profession*

Medication Details

No of Items*

Item 1

Medication Name*

(including strength and form e.g. paracetamol 500mg tablets)

Directions*

(e.g. two to be taken four times a day)

Quantity*

(e.g. 100)

Item 2

Medication Name*

(including strength and form e.g. paracetamol 500mg tablets)

Directions*

(e.g. two to be taken four times a day)

Quantity*

(e.g. 100)

Item 3

Medication Name*

(including strength and form e.g. paracetamol 500mg tablets)

Directions*

(e.g. two to be taken four times a day)

Quantity*

(e.g. 100)

For private prescriptions to be valid, they must be written by a prescriber registered within the European Union (EU). Prescriptions will be verified before supply.

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Phone

This field is for validation purposes and should be left unchanged.

38532