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Online prescription order - Pencoed patients only
Your Contact Information
*E-Mail:
Valid e-mail is required
*NHS Number:
This is a 10 digit number
*Patient`s First Name:
The person taking the medicine
*Patient`s Last Name:
*Patient`s Date of Birth:
DD/MM/YY
*Patient`s Address Line 1:
House number and street name
Patient`s Address Line 2:
Village e.g. Brynna
*Patient`s Post Code:
*Phone:
In case we need to contact you
Your prescription order
*Drug 1:
Name, strength & quantity
Drug 2:
e.g. Frumil tablets 40mg x 28
Drug 3:
e.g. Evorel patches 1mg x 24
Drug 4:
e.g. Diprobase cream 50g
Drug 5:
Drug 6:
Drug 7:
Drug 8:
Drug 9:
Drug 10:
*What do you want us to do with the completed prescription?
Select
one of the options below:
Patient will collect from Pencoed surgery
Send to Sheppards Pencoed
Send to Richards Pencoed
Send to Tescos Bridgend
Send to Boots
Send to Brackla Pharmacy
Scroll down to select
Any special message to us (but ONLY if it relates to your prescription order please):
This is optional
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in UPPER CASE.
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