Would you like to simplify how you get your NHS medication?
 

Simplified NHS prescription service

Your Details

    Other:
First Name
Surname
Date of birth
Address
Postcode
Fill in your details below and tick which method of contact you prefer.
* Please supply a contact number in case we need to contact you urgently
Would you like your items delivered to the above address?
Address
Postcode

Date next prescription is due

Due date

Exemption

Do you pay for your prescriptions?
A patient is exempt if they do not have to pay for their prescriptions, if they:














Declaration and Concent

I declare that the patient does not have to pay NHS prescription charges, is properly entitled to exemption and that the information is true and complete. I also declare that if the entitlement changes, I will tell Chemist4U immediately on 01695 474433, and I understand that if I do not do so, appropriate action may be taken.

I understand the services you provide and want to register to use them. I understand EPS nomination and nominate you to collect my prescriptions on my behalf either via EPS or direct from my GP. I understand that by signing this from I give permission for my prescriptions and information about my repeat medicines to be sent electronically between my doctor and Chemist4U

To improve your experience we may post your items through your letterbox subject to size. I confirm and consent, that it is safe and suitable for Chemist-4-U to post the medication through the letterbox.
    Other:
First Name
Surname
Date of birth
Address
Postcode
Contact Number
Signature
Agent Id (if applicable)