This form has been created to enable parents/guardians to order their children's regular repeat prescriptions ONLY .
This is due to the limitation of the NHS Wales App where you can only be over 16 to order repeat medication.
If you are over the age of 16 you will need to register and sign up to the NHS Wales App to order your repeat medications.
NHS Wales App
THIS FORM SHOULD NOT BE USED TO SUBMIT MEDICATION REQUESTS THAT ARE NOT ON A REGULAR REPEAT Please allow 72 hours for prescription processing (Mon-Fri) and extra time for your nominated pharmacy to dispense the medication
We would advise that you order any repeat medication 7 days before it is due. This will allow the surgery time to process the prescription and for the pharmacy to prepare and dispense it. Any requests which are submitted earlier than 7 days will not be processed.
Wherever possible we will send it to your local nominated pharmacy. If you do not have a designated pharmacy and would like your prescription to be sent to them please let us know who is your chosen pharmacy is when you make your request.
Child's Full Name
Childs Date of Birth
Childs Registered Address
Parent/Guardian Contact Full Name
Parent/Guardian Contact Number
Medication Required
Upload photo of repeat slip to avoid completing information below
Please list all medications required to include Name, Strength / Dosage and quantity required. You can request up to 10 items using this form. Please list individual items below
Item 1 - Medication Name, Strength / Dosage, Quantity
Item 2 - Medication Name, Strength / Dosage, Quantity
Item 3 - Medication Name, Strength / Dosage, Quantity
Item 4 - Medication Name, Strength / Dosage, Quantity
Item 5 - Medication Name, Strength / Dosage, Quantity
Item 6 - Medication Name, Strength / Dosage, Quantity
Item 7 - Medication Name, Strength / Dosage, Quantity
Item 8 - Medication Name, Strength / Dosage, Quantity
Item 9 - Medication Name, Strength / Dosage, Quantity
Item 10 - Medication Name, Strength / Dosage, Quantity
Attach copy of repeat slip form if easier
Dewiswch... Aneurin Evans - Hood Rd Brockway Day Lewis Philips Vere St Boots Barry Evans Park Crescent High Street Pharmacy Highlight Pharmacy Llan Martin Pharmacy Phillips - Barry Rd Phillips -Court Rd Rhoose Pharmacy St Brides Pharmacy Boots -Queen St Boots - Penarth Boots - Cardiff Bay Boots Capital Centre Allway Allied Pharmacy - Waterfront Allied Pharmacy - Holton Rd None - Collect from West Quay Surgery Collection Point i.e. name of chemist
Privacy Protection
Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy. This information is not shared with any third party organisations. This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form
