Prescriptions

We offer a repeat prescription service for our patients. If you need to renew your prescription simply complete the form below and one of our clinical team will be in touch. Prescription fees apply to non-members of the practice, these are listed on our fees page. If you need to contact us to discuss your prescription further please call us on 020 7730 8835 or contact us here.

Name

First Name

Last Name

Phone Number

Registered patient of SSM

Please tick whether or not you are a registered patient of Sloane Square Medical.

Yes, I am a registered patient

No, I am not a registered patient

Past medical history

Please briefly describe any previous medical history in the box below.

Current medication

Please list any medication you are currently taking below.

Allergies

Please detail any allergies you have below.

Presenting complaint

Please describe below your current presenting complaint and reason for your prescription request.

Where would you like your prescription form to be sent?

Please select one of the following options.

Name of your local pharmacy

If you have selected for the prescription form to be sent to your local pharmacy, please provide the name of the pharmacy.

Address of your local pharmacy

If you have selected for the prescription form to be sent to your local pharmacy, please provide the address of the pharmacy.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email address of local pharmacy

If you have selected for the prescription form to be sent to your local pharmacy, please provide the email address of the pharmacy.

Local pharmacy telephone number

If you have selected for the prescription form to be sent to your local pharmacy, please provide the telephone number of the pharmacy.

Country

(###)

###

####