Pharmaself machine registration

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

Collection details

Who should the pharmacy contact with collection details?

Myself

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

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

Tell us whether you accept cookies

Collection details

Prescription payment status

Consent and declaration