Your Name:
Doctor's Name:
Your Address:
Surgery Address:
Your Tel:
Your E-mail:
I would like Gardners Chemist to collect my repeat prescription from the above surgery until
further notice.
This form authorises us to collect prescriptions on your behalf. You must stil
l contact us when
you order a prescription so we know when to collect it for you.
© 2008 Gardners Chemist. All rights reserved.
