Pharmaself machine registration

Section

Collection details

Who should the pharmacy contact with collection details?

Myself

Nominated representative

Full name of nominated representative:

Mobile number of nominated representative:

Prescription payment status

Do you pay for your prescriptions upon collection?

I currently pay for my prescriptions

I am currently exempt from prescription charges

Important: If you claim an exemption and it turns out to be incorrect, you may be fined by the NHS Business Services Authority (NHSBSA).
Please ensure your exemption status is valid and up to date.

Consent and declaration

Confirmation

Yes, l wish for Chipping Norton Surgery & Dispensary to make my prescription available for collection from the Automated Prescription Collection Point.

Please note – some medicines may not be suitable for collection from the collection point and will need to be collected in person during normal dispensary opening hours.

All information supplied to us will be treated in the strictest confidence and will be stored in accordance with current GDPR and Data Protection Act legislation and in line with NHS Information Governance.

By ticking the box above, I confirm that:

I consent to text messages regarding collection of medication to be sent to the number stated above

I agree to abide by the codes of conduct

I understand it is my responsibility to inform the dispensary if any of the above details change

I understand my prescription must be collected within 5 days of being informed

I understand that controlled drugs and refrigerated items cannot be collected from PharmaSelf24

Signature

Date

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Section

Collection details

Prescription payment status

Consent and declaration