First Name *

Last Name *

Gender * Select Gender MALE FEMALE OTHER

Phone Number *

NHS No (if known)

Address 1 *

Address 2

Address 3

City *

Postcode *

Do you pay for your prescription or have an exemption? Yes I pay every time I get a prescription A - is under 16 years of age B - is 16, 17 or 18 or in full time education C - is 60 years of age or over D - has a valid maternity exemption E - has a valid medical exemption F - a valid payment certificate G - a valid war pension exemption L - is named on a current HC2 charges certificate X - was prescribed free of charge contraceptive H - gets income support or income income related employment and support allowance K - gets income based job seekers allowance M - is entitled to, or named on, a valid NHS tax credit exemption certificate S - has a partner who gets pension credit guarantee credit (PCGC)

Do you re-order your prescriptions? * Yes No

How do you order your medicines? please select below Order by taking repeat slips into G.P. surgery Order by online access provided by G.P. surgery Order managed by the pharmacy

If unavailable, i would like: please select below Package to be posted Delivered to a neighbour Delivered to a safe place

Email Address *

Password *