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Community Pharmacy Patient Questionnaire 2019-2020 Results
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EPS
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Repeat Prescription Registration/EPS Nomination form
(Complete one form for each patient)
*
Indicates required field
Name
*
First
Last
Address and Phone Number
*
Give your full address including postcode here and your phone number
Date of Birth and NHS number
*
Enter your date of birth and NHS number here
Do you pay for your prescriptions?
*
Answer - Yes or NO, If NO give the exemption that applies.
GP's Information
GP's Name, Address and phone number
*
Fill in the name of your GP, the address and phone number
Statement of Agreement
I give my consent to Radcliffe day and night pharmacy to retain my repeat slip, order my repeat prescription and collect from my GP surgery (either in person, postal or by electronic transfer).
I agree to Radcliffe day and night Pharmacy contacting myself or my GP’s surgery to verify my required prescription items, or to advise me my repeat prescription is ready for collection or delivery.
I give my permission for Radcliffe day and night pharmacy to hold the information provided on this form.
Radcliffe day and night pharmacy may contact you regarding healthcare services offered by the pharmacy.
I will contact Radcliffe day and night pharmacy if I wish to change this agreement.
By submitting this form, you consent to the above statement of agreement.
Submit
Company Reg. No. 07763598 Premises Reg No. 1117168
