Request a prescription

Name(Required)

First name Last name

Date of birth(Required)

Current age

Delivery address(Required)

Where would you like your prescription/medication to be delivered?

Address Town or city Post code

Mobile phone number(Required)

List(Required)

Medication name

Give dose (if different at different times of the day, please specify)

How many times a day?

How many days' supply do you need?

Please choose how you wish to receive your prescription/medication(Required)

Please note that prescriptions sent in the post will be sent by first class post and thus delivery date is not confirmed. If you choose CloudRx and are ordering a controlled-drug*, CloudRx must wait for the handwritten controlled drug prescription before they may dispatch the medication. If you choose a prescription by SignatureRx, the e-token is available as soon as the medication is prescribed, but this service cannot be used for controlled drug prescriptions. *What is a controlled drug? (a) a psychostimulant (ADHD) medication such as methylphenidate (including Concerta XL, Xaggitin XL, Ritalin, Equasym, and Medikinet), lisdexamfetamine (Elvanse) or dexafemtamine (Amfexa) (b) another conrolled drug such as pregabalin, or temazepam. Full details can be seen at https://drandrewiles.link/cd

I wish to receive a paper prescription in the post

I wish to receive the medication in the post from CloudRx

I wish to receive an e-token from SignatureRx to take to my chosen pharmacy

Prescribing fee(Required)

Price:

Please note that this does not include the cost of your medication, which will be payable to your pharmacy provider.

Payment Method(Required)

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name