Pharmacy Nomination Form

As the majority of prescriptions are now required to be sent electronically to the pharmacy, we are requesting patients to nominate a pharmacy they wish to collect their prescriptions from.

Last Updated: 07/01/2020

Your Details

First Name *

Surname *

Date of Birth *

Phone Number

Pharmacy Nomination

If the pharmacy you require is NOT on the list, please select other and type in the NAME and POST CODE of the pharmacy you wish to collect your prescription from.

Please select a pharmacy from this list or other to enter your own. *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Pharmacy Nomination Form

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