Registration Form

Doorstep Pharmacy Prescription Collection and Delivery Registration Form

Please enter

I am the patient

I am the patient's representative

Title

Please enter your SURNAME

Please enter your FIRST NAME

Please enter any MIDDLE NAME or initial

Date of Birth ( mm/dd/yyyy)

Please enter your NHS. No. If known

Please enter your FULL ADDRESS

Please enter your POSTCODE

YOUR TELEPHONE No.

Please enter YOUR EMAIL

Now please give us your doctor's details. Please ensure you give us the exact address or branch so that we can collect your prescriptions on your behalf from the correct place.

Please enter your DOCTOR's name

Please enter your DOCTOR's FULL ADDRESS

Your DOCTOR's POSTCODE

SURGERY TELEPHONE NO.

SURGERY EMAIL ADDRESS

SURGERY FAX NO. If known

I hereby give consent to Doorstep Pharmacy Ltd to collect , either in person, by post or electronic transfer, my prescriptions from the surgery mentioned above and to dispense them on my behalf, until I give further notice of any changes to this arrangement. I confirm that these instructions supersede any earlier direction of prescriptions that I may have set up. I CONFIRM THAT ALL THE INFORMATION THAT I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE.

Consent

I consent as above

I do not consent

Consent Date (mm/dd/yyyy)

Thank you for registering with Doorstep Pharmacy's prescription collection and home delivery service. We will contact you shortly to confirm your instructions and look forward to welcoming you on board.