Chemicrest Pharmacy of Hockley and Golden Cross Pharmacy of Rochford

We have an arrangement with the following surgeries to dispense repeat prescriptions to patients -

1. Rochford Medical Practice, Rochford
2. The Puzey Family Practice, Rochford
3. Rochford and Hawkwell GP Practice, Leecon Way, Rochford
4. Ashingdon Medical Centre, Dr Singh
5. Jones Family Practice, Hockley
6. Greensward Surgery, Hockley

We can also serve patients registered with other surgeries. Please contact us to arrange this.

This service is only available to patients of these surgeries who have a valid, up-to-date, repeat prescription.

First Names:
Last Name:
Date of Birth:	(dd/mm/yyyy)
Address:
Phone Number:
Email Address:
Surgery:

Please tell us what medication you require. Be specific and check your spelling. Please take all details from your repeat prescription record slip.

Drug Name	Strength

If you require more than 8 items, please submit another request.

Please enter here any comments that you may have about this service:

CONFIDENTIALITY - TERMS AND CONDITIONS
The internet is not secure, and the transmission of data to request medication is entirely at the patient's own risk. The Pharmacy accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above and understand that by ticking this box I give my consent for Chemicrest to order, pick up and dispense this repeat prescription.

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