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Cosmeticare
Vasectomy Clinic

NHS Direct



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Repeat Prescription Form

Once ordered your prescription will be ready in 2 working days.  There is no need to contact the surgery beforehand.

Your name:
Email:
Date of birth
Work Tel.
Home Tel.
Mobile Tel.
Fax No.

The following information as seen on your repeat slip.

Quantity Strength Description
Request 1.
Request 2.
Request 3.
Request 4.
Request 5.
Request 6.
  .    
Additional Information
 
  .