Purchasing medication as a non-CRGW patient

Name*
Date of birth*
MM slash DD slash YYYY
Address*
Email*
Phone*
Upload a copy of your prescription here. We cannot prescribe without this.
Max. file size: 256 MB.
Do you have any allergies?
- Yes
- No
Outline allergies*
What date do you need the medication by?*
MM slash DD slash YYYY
The clinic I am having treatment at is:*
I am having treatment at the above named clinic. They require me to have medication which they have asked me to obtain. I have asked CRGW to prescribe these drugs for me. This box is to confirm that I am aware that CRGW are only prescribing these drugs on my instruction. I fully understand that CRGW and/or its staff take no responsibility for the use and administration of these drugs, as well as any side effects of this medication.*
I am aware that once I have completed this form and sent my prescription, I will be sent them an invoice by email. Once payment is made CRGW will send the prescription to Stork (who dispense for CRGW) who would then contact me to arrange delivery.*
I am aware there is a £75 administration fee for this process (for up to 3 different medications)*
Any questions or comments?
Email
This field is for validation purposes and should be left unchanged.