Rishton & Great Harwood Surgery

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Repeat Prescription Form
Please complete this form then click the submit button.
Your Personal Details
Name:
Address:
 
 
 
Postcode:
Date of birth:
Your Surgery name
Prescription items required
Date when Prescription is ready to collect
I hereby authorise standish pharmacy to collect and dispense my Prescription
(You must tick this box)

Please check your details above then press to submit your enquiry


15, Preston Road, Standish, WN6 0HR........ Tel: 01257 421220 ........www.standishpharmacy.co.uk

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