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Your Details

Title*
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Enter Full Name* Date Of Birth*
Date* Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month* Select January February March April May June July August September October November December Year* Select 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Mobile Number Address 1* Address 2 Town City Post Code* Next Prescription Due Date* NHS Number: if you remember

Select your status

Do you pay for your prescription:    No   Yes

Select Your Exemption Type Select Exemption Not Exempt Under 16 years of age 16 17 18 and in full time education 60 years of age or over Valid maternity exemption certificate Valid medical exemption certificate Valid prescription pre-payment certificate Valid war pension exemption certificate Named on current HC2 charges certificate Prescribed free-of-charge contraceptives Get income support(IS) Get income based job seekers allowance ((JSB)IB) Entitled to, or named on, a valid NHS tax credit exemption certificate Partner who gets pension credit gurantee credit(PCGC)

Delivery Service?    Delivery   Collection

I give my consent for the following areas:

✔ Order my repeat prescription from the surgery (if applicable)
✔ Take my completed repeat prescriptions request slip to the surgery
✔ Collect my prescription from the surgery
✔ Delivery my medication to the address stated above
✔ Store my medications securely to the pharmacy

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Consent: any confidential information supplied will be processed and used for the purpose above. This may also include:

• Sharing information with your GP practice
• Storing for record keeping purposes

Earls Court Chemist will not pass your details on to third parties. Every effort has been made to protect your's confidentiality.

I understand that i can change or amend this consent at any time and will inform Earls Court Chemist at the earliest opportunity.

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