Patient Nomination Form

Please complete the form below to nominate us (Cotteridge Pharmacy) to receive your prescriptions electronically.

A full explanation of the Electronic Prescription Service can be found by clicking here.

Title

Name

First Name

Last Name

Address 1

Address 2

City

Post Code

Date of Birth

DD/MM/YYY

Telephone

Name of GP Surgery

Would you like your medication delivered for FREE?

Local area only

Payment Exemption

Please confirm:

I understand the NHS Electronic Prescription Service. I confirm that I have nominated Cotteridge Pharmacy to receive my prescriptions electronically. I understand that I can change or remove my nomination at any time.