Nominate a pharmacy

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

We will only use this email address for correspondence in relation to this request and will not sell it onto third parties.

You confirm you would like to have your prescription sent electronically.

Pharmacy Details

Pharmacy Name:

Pharmacy Address:

Pharmacy Postcode:

Not sure what your closest pharmacy is?

Use the NHS Find a Pharmacy tool.