Part One:
Your details - as registered at your local GP

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Title
MrMrsMsOther

Full name

Address

Date of Birth

Mobile

Part Two:
Receiving your prescription

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Please specify whether you require delivery or wish to collect your prescription:

CollectionDelivery (currently unavailable)
Your prescriptions will be ready to collect from your nomitated pharmacy in Part Three of this
form.

Part Three:
Current services

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Please specify the pharmacy you would like to dispense your prescriptions:
Ashbourne PharmacyBanstead PharmacyBarlow PharmacyBarming PharmacyBattle Hill PharmacyBerwick- Well Close PharmacyBiggleswade PharmacyBlaby PharmacyBloomfield PharmacyBovey Tracey Fountain courtBoxalls PharmacyBrannam PharmacyBrockwell PharmacyBuxton PharmacyChain Lane PharmacyChapel Street PharmacyClive Parade PharmacyClowne PharmacyCoulby PharmacyCrich PharmacyDelamere PharmacyDudley PharmacyDuffield PharmacyFountain Street PharmacyGorton PharmacyGrove Green PharmacyHasland PharmacyHealey PharmacyHollington PharmacyHolme Hall PharmacyLegh Street PharmacyLonghill PharmacyMiddle Warren PharmacyMiddleton PharmacyMoorlands PharmacyMount PharmacyMount Road PharmacyNabbs PharmacyPorterbrook PharmacyPortway PharmacyRainhill PharmacyRussell PharmacySherwood PharmacySkipton PharmacySpringfield PharmacyTorkard PharmacyTweedmouth PharmacyVernon St PharmacyVillers PharmacyWellfield PharmacyWellington House PharmacyWest Street PharmacyWhitwick Road PharmacyWinterbottom PharmacyWitham Pharmacy

Please specify which surgery you are registered with:

Part Four:
Payment & Exemption

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Please specify whether you pay for your prescriptions or if you have an exemption:
--- Please Select ---No Exemption16, 17 or 18 and in full-time education60 years of age or overValid maternity exemption certificateValid medical exemption certificateValid prescription pre-payment certificateValid War Pension exemption certificateNamed on a current HC2 charges certificatePrescribed free-of-charge contraceptivesIncome support or income-related Employment and Support AllowanceIncome-based Jobseeker’s AllowanceEntitled to, named on, a valid NHS Tax Credit Exemption CertificatePartner gets Pension Credit guarantee credit (PCGC)Under 16 years of age

Part Five:
Register to use this service

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I am the patient/patient’s representative and would like to register to use the selected pharmacy in
this form for the NHS Prescription Service.
I understand EPS nomination and nominate Allied Pharmacies to dispense my prescriptions.
By signing this form, I give permission for information about my repeat medicines to be sent between my
doctor and the selected pharmacy.

If I have stated I am exempt from payment, I confirm I am properly entitled to exemption and that if my
entitlement changes, I will tell you immediately on 0127 088 2049.

Signature

Date