Electronic Prescription Service - Consent form

Patient Details:

Name (required)

Address (required)

Date of Birth (required)

Telephone Number (required)

Gender (required): MaleFemale

NHS number (required)

This can be found on the top right hand corner of your prescription

If you are a representative of the patient, please fill in your details in all of the fields below:

Name

Address

Relationship to Patient

Telephone Number

I would like to nominate:

Pharmacy Name and address (required)
---Newline Pharmacy ( Dereham Terrace Stakeford NE62 5UR )Crescent Pharmacy (110 Alexandra Road Ashington NE63 9LU )Backworth Pharmacy (Unit 2 Old Co-op Buildings Church Road Backworth NE27 0JE)Coast Road Pharmacy (11 Coast Road Wallsend NE28 9HP)Willington Quay Pharmacy (13 Station Road Willington Quay NE28 6NB )

to receive my prescriptions via the Electronic Prescription Service.

Please tick here if you do not wish to be contacted about healthcare services offered by this pharmacy:
Do not contact me

I have read and understand what the EPS is all about and what nomination means.

Signature (required) - Simply enter your name as your electronic signature below:

Enter today's date (required) (For example DD/MM/YYYY )

To be retained by the pharmacy