If your Surgery is not included on the form please contact us to find out whether or not we will be able to assist you.
Date of Birth
Allander SurgeryAnnfieldAshton HouseBank Street SurgeryBarony Medical CentreBridgeton Health CentreCarntyne Medical CentreCommonwealth Village Medical PracticeFernbank Medical CentreGallowgate SurgeryGlenmill Medical CentreGorbals Health CentreGovanhill Health CentreHunter StreetLightburn Medical CentreMain Street Medical PracticeMeadowpark SurgeryParkhead Health CentreQueens CrescentSandyford SurgerySpringburn Health CentreTownhead Health Centre (Yellow Practice)Parade Group Medical (Grey Practice)Whitevale Medical GroupWoodside Health Centre
Provide your full address
Please write down the Name, Strength and Quantity of each medicine you require e.g. Atenelol Tablets 25mg x 28. Only order what you need.
Please sign here