High Field Surgery Website - On Line Prescription Form

Online Prescription Request Form

Online Prescription Security and Cookies

Please note this is NOT a secure form - it is sent to us via computers that do not belong to the NHS in a non-encrypted format. Complete confidentiality for this type of repeat prescription request can not be guaranteed. However this will be no less secure than a normal email. If you are unsure about using this service please feel free to use our other ways to order repeat prescriptions.

Personal information

These details are required so that we can process your prescription. The Chemist will only collect your prescription if you have agreed this method of collection with them in advance.

NHS Number
Date Of Birth
Contact Telephone
Collect From

Repeat medications needed: Medication e.g. Furosemide; Strength: e.g. 20mg; Amount e.g. 56 tablets. Medication 1 Strength 1 Amount 1
Medication 2 Strength 2 Amount 2
Medication 3 Strength 3 Amount 3
Medication 4 Strength 4 Amount 4
Medication 5 Strength 5 Amount 5
Medication 6 Strength 6 Amount 6
Medication 7 Strength 7 Amount 7
Medication 8 Strength 8 Amount 8

Further information

If you select 'save these details' you can save your drugs and strengths on your computer using a cookie. It is necessary to have cookies and JavaScript enabled (and allow 'active content' if the browser blocks it). Please be aware that it is possible that the data saved as a cookie could be seen by other users of the same PC.

Any other information?
Save these details

High Field Surgery Holtdale Approach, Leeds LS16 7RX

Online Prescription Request Form

Online Prescription Security and Cookies

High Field Surgery
Holtdale Approach, Leeds LS16 7RX