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Home Prescription Request Form

Prescription Request Form

Prescription Request Form

These forms can only be used by prescribers registered with BSO

Cipher numbers are not transferable across practices. Prescribers working in multiple practices must have a separate unique cipher number for each practice or clinical setting.
Please Choose Prescriber Type:*
Non-Medical Prescribers include: Nurse Independent Supplementary Prescribers, Pharmacist Independent Supplementary Prescribers, Physiotherapists, Podiatrists, Optometrists
- GP
- Dentist
- Community Nurse Practitioner Prescriber
- Non Medical Prescriber
- Registered PCD1 Prescriber
- Community Pharmacy - PV1
- Registered SP1 Prescriber
- Registered SP2 Prescriber
Prescriber Cipher Number*
NB prescriber cipher number can be found on your prescription pad or DLRT information note and must match the registered prescriber name
Prescriber Name*
First Last
Pharmacy Prescriber Cipher Number*
NB prescriber cipher number can be found on your prescription pad or DLRT information note and must match the registered community pharmacy name
Community Pharmacy Name*
NB - Entering an incorrect name may result in this submission being returned. Community Pharmacy Name must be the registered pharmacy name (first line of the 'name' column in the pharmaceutical list). To access the pharmaceutical list for registered name, please click HERE
Email Address*
Order Date*
DD slash MM slash YYYY
Please send the following:*
- HS21N
- HS21NCS
** Only one selection per order is permitted, if you require more than one type of prescription pad a separate eForm must be submitted for each type **
Please send the following:*
- HS21D
Please send the following:*
- HS21
- HS21CS
- HS21S
** Only one selection per order is permitted, if you require more than one type of prescription pad a separate eForm must be submitted for each type **
Please send the following:*
- HS21X
- HS21XCS
** Only one selection per order is permitted, if you require more than one type of prescription pad a separate eForm must be submitted for each type **
Please send the following:*
- PCD1
Please send the following:*
- PV1/MA
- PV1 Emergency Supply - Pandemic
** Only one selection per order is permitted, if you require more than one type of prescription pad a separate eForm must be submitted for each type **
Please send the following:*
- SP1
Please send the following:*
- SP2
HS21
Description: Pad Prescription Doctor
Unit: 4 x Pad/100
Product Code: HS21
HS21CS
Description: Cut Sheet Prescription form Doctor
Unit: Set/3000
Product Code: HS21CS

** THIS PRODUCT CAN ONLY BE ORDERED EVERY SEVEN WORKING DAYS **
HS21S
Description: Stock Requisition Pad
Unit: 100
Product Code: HS21S
HS21D
Description: Pad Prescription Dentist
Unit: 1x100
Product Code: HS21D

** THIS PRODUCT CAN ONLY BE ORDERED EVERY SEVEN WORKING DAYS **
HS21N
Description: Pad Prescription Nurse
Unit: Pad/100
Product Code: HS21N
HS21N - Please select quantity required*
HS21X
Description: Pad Prescription Non Med Prescriber
Unit: Pad/100
Product Code: HS21X
HS21X - Please select quantity required*
HS21NCS
Description: Cut Sheet Prescription form Nurse
Unit: Set/100
Product Code: HS21NCS
HS21NCS - Please select quantity required*
HS21XCS
Description: Cut Sheet Prescription form Non Medical Prescriber
Unit: Set/200
Product Code: HS21XCS
HS21XCS - Please select quantity required*
SP1
Description: Substitute Prescribing Pad
Unit: 100 ( 50x2 )
Product Code: SP1
SP1 - Please select quantity required*
PV1/MA
Description: Pharmacy Voucher
Unit: Set/200
Product Code: PV1/MA

** THIS PRODUCT CAN ONLY BE ORDERED EVERY SEVEN WORKING DAYS **
PV1 Emergency Supply - Pandemic
Description: 2 Part Set
Unit: Set/200
Product Code: PV1 Emergency Supply - Pandemic
PCD1
Description: Prescription Private Controlled Drugs
Unit: Pad/25
Product Code: PCD1
SP2
Description: Cut Sheet Substitute Prescriber Form
Unit: Set/1000
Product Code: SP2
SP2 - Please select quantity required*
** Please be aware all orders can only be sent to your registered address **