Request prescription synchronisation – The Birchwood and Sollershott Surgeries

Fill in the form below to request prescription synchronisation.

Name*
First name Surname
Date of birth*
Day
Month
Year
NHS Number*
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Email address*
Enter Email Confirm Email
Address*
Street Address Town or city Post code
Daytime telephone number*
Mobile telephone number
Named GP (if known)
Please enter the name and address of your chosen pharmacy*
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How many prescriptions do you need to synchronise and what are they for?
Additional comments
Not for urgent medical help*
Yes, I understand this form is NOT for urgent medical help
Consent*
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 days calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.
Phone
This field is for validation purposes and should be left unchanged.