Prescriptions Order Form

Order your prescriptions using this form

Your Title *

First Name *

Last Name *

Phone Number (Home)

Phone Number (Mobile)

Email Address *

Date of Birth *

Address Line 1 *

Address Line 2 *

Address Line 3

Postcode *

Exemption

Are you exempt from prescription payments? Tick "NO" if you pay for your prescriptions or "YES" if you do not.

The NHS regularly carries out counter fraud checks when patients say that they are exempt from prescription charges. The NHS also requires us to ask you for evidence that you are exempt from paying prescription charges for some types of exemption and to notify them if we do not see this evidence. The NHS can fine you if you wrongly claim to be exempt from paying for your prescriptions even if it is a mistake.

YesNo

Surgery Details

Name of surgery

Name of GP

Prescription details

Please write down the Name, Strength and Quantity of each medicine you require e.g. Atenelol Tablets 25mg x 28. Only order what you need.

By ticking this box you are consenting to your future prescriptions being sent electronically to Daytom Pharmacy. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.

I agree