Private Prescription Request Patient DetailsTell us your details firstFull Name*Address* Street Address City ZIP / Postal Code Date of Birth* Date Format: DD slash MM slash YYYY Preferred Contact Method*EmailPhoneMobileEmail* Phone*Mobile*Do you require your medication to be posted?*NoYes - £4.40 for 1st classYes - £3.90 for 2nd classYou 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 DetailsFull Name*Address* Street Address Address Line 2 City ZIP / Postal Code Profession*Select a professionDoctorDentistPharmacistNurseOptometristMedication DetailsNo of Items*123Item 1Medication 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 2Medication 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 3Medication 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. 20159