Online Prescriptions

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Dr Layth J Delaimy Tel: 01932 252425

Online Prescriptions

Please note: If the Doctor wants you to have repeat prescriptions, please ask at least 48 hours before you run out - you will be provided with a Repeat Prescription. Request form, which can be found attached to your latest prescription, should be handed in to Reception or sent with a stamped addressed envelope, alternatively you may fill a form at the secretary desk. Telephone requests cannot be taken.
You can use the form below. The form is not encrypted and therefore complete confidentiality cannot be guaranteed. Using this form is like sending a postcard request using the Royal Mail.

Your Surname: *
Your Firstname:*
Your Date of Birth: *
Contact Telephone: *
*You must provide this information
1st Drug	How often? Amount (e.g. 30 tablets or 100 mls.)
2nd Drug	How often? Amount (e.g. 30 tablets or 100 mls.)
3rd Drug	How often? Amount (e.g. 30 tablets or 100 mls.)
4th Drug	How often? Amount (e.g. 30 tablets or 100 mls.)
5th Drug	How often? Amount (e.g. 30 tablets or 100 mls.)
How long do you want the prescription to last: (Weeks)
Do you want the prescription post dated?:
Any other comment?

Ashley
Medical Practice
1a Crutchfield Lane
Walton-on-Thames
Surrey
KT12 2QY

Tel: 01932 252425
Fax: 01932 886912