Dr Rial & Partners
Waterside Health Centre
Online Prescription Request
E mail address
Name*
Date of Birth*
Contact number*
Enter any other details here
It is recommended that you print this page for your records before submitting
1*.
3.
2.
8.
7.
4.
6.
5.
Drug Name
Strength
Please check this box before submission to acknowledge that this prescription request is being sent un encrypted via the world wide web