Nominate Us

To nominate us for all your prescription needs please complete the form below.

Your Name*

Your Address*

Date of Birth*

Address*

Post Code*

Telephone Number*

Special notes (e.g, knock hard on the door, ring the bell etc)*

Surgery Details

Your GP surgery name (If you are not the patient? Please specify your relationship to the patient)*

Exemption & I.d.

Are you exempt from prescription payments? (Tick "NO" if you pay for your prescriptions or "YES" if*

-- Select --

The NHS regularly carries out counter fraud checks when patients say that they are exempt from prescription charges. The NHS also requires us to ask you for evidence that you are exempt from paying prescription charges for some types of exemption and to notify them if we do not see this evidence. The NHS can fine you if you wrongly claim to be exempt from paying for your prescriptions even if it is a mistake. I understand that if there are any changes to my exemption status, I will contact Prudhoe Pharmacy and failure to do this may result in action by the NHS

If say YES to exemption from prescription charges please add reasons below*

Type Yes if you agree*

Declarations

By typing 'YES' below this box you are consenting to send your prescriptions electronically to Prudhoe Pharmacy. You can change this nomination at any time. I confirm that Prudhoe Pharmacy bears no responsibility for any parcel damaged after delivery due to external factors such as pets and children in the household. I acknowledge that only I, the patient, will open the parcel.

Type YES if you agree to above*