Wendover Heights Veterinary Centre

Tring Road, Halton, Aylesbury, Bucks HP22 5PN  01296 623439

Request for repeat prescription (fields marked * are required fields)

PLEASE NOTE THAT WE REQUIRE 24 HOURS’ NOTICE FOR PRESCRIPTIONS.

If your request is urgent or you require several items it is advisable to telephone the practice.

Information recorded on this page will be used for internal use only and will not be disclosed to third parties.

Please specify which surgery you

wish to collect from*

Forename or initials*

Surname*

House number or name*

Address*

Town*

County

Postcode*

Contact telephone number(s)*

Animal's name*

Exact name of medication/product*

Quantity

Drug strength, dose, etc.*

Please enter any other additional

information

E-mail

Type of animal, i.e. dog, cat,

rabbit, horse, etc.*