Falls Pharmacy
Falls Pharmacy

Prescription Request

Please complete the form below and we will return it to your GP, please allow 4 days for collection.

This form can be used to submit requests for repeat prescriptions from a number of local Doctor's surgeries. If your Surgery is not on the drop-down list then we are unable to to accept your request.
Name*
1st Line of your address*
Post Code*

DD/MM/YYYY

Date of Birth*
Doctor's Name
Surgery*
Items Required*
*required
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