Prescription Request Form

    For registered Mayor Medical clients use only. If you are not registered please complete our patient registration form. Please submit your medication requests electronically.
    Prescriptions will be sent via First Class post within 3 working days.

    Full Name*

    Email Address*

    Address*

    Medication Required*

    Frequency*

    If other

    Duration Required

    If other

    Add more medications:

    Medication Required*

    Frequency*

    If other

    Duration Required

    If other

    Add more medications:

    Medication Required*

    Frequency*

    If other

    Duration Required

    If other

    Add more medications:

    Medication Required*

    Frequency*

    If other

    Duration Required

    If other

    Add more medications:

    Medication Required*

    Frequency*

    If other

    Duration Required

    If other

    Full Name:

    Date of Birth: --

    Address:

    Note: Medication Requested will be posted in next 3 working days to .

    --SET #1--
    Medication Requested:

    Frequency:
    If other:

    Amount Required:
    If other:

    --SET #2--
    Medication Requested:

    Frequency:
    If other:

    Duration Required:
    If other:

    --SET #3--
    Medication Requested:

    Frequency:
    If other:

    Duration Required:
    If other:

    --SET #4--
    Medication Requested:

    Frequency:
    If other:

    Duration Required:
    If other:

    --SET #5--
    Medication Requested:

    Frequency:
    If other:

    Duration Required:
    If other: