Prescription Question We’ll ask you for: your first and last name, date of birth, sex, postcode, email and phone number if applicable, the details of the person you are completing the form on behalf of You can also phone us on 0118 973 2678. Who are you completing this form for? Yourself Someone else For example, on behalf of a child or dependentWhat is your name? First Optional Last Optional What is your date of birth? DD slash MM slash YYYY What is your sex? Male Female Other As recorded on your medical recordWhat is your postcode?The one used to register with your GPWhat is your phone number?What is your email address? Anyone else with access to your email account may see responses sent to youNamed GP (if known): OptionalWhat is your prescription question?Confirmation I confirm that my enquiry is not urgent, and it may take up to 3 working days before I receive a reply.
