Your First Name*

Your Last Name*

Date of Birth*

Address Line 1*

Address Line 2*

City*

Postcode*

I confirm that it is safe and suitable for medication to be post through the letterbox, subject to size.*

Do you pay*
Yes - I pay for my prescriptionsNo - I'm exempt from paying for prescriptions

Reason*
—Please choose an option—Is 60 years of age or overIs under 16 year of ageIs 16, 17 or 18 and in full time educationHas a maternity exemption certificateHas a medical exemption certificateHas a prescription pre-payment certificateHas a war pension exemption certificateIs named on a current HC2 changes certificateWas prescribed free-of-charge contraceptivesGets Income Support (IS)Gets Income based Jobseeker's AllowanceIs entitled to, or named on a valid NHS Tax Credit exemption certificateHas a partner who gets Pension Credit guarantee credit

Email

Phone*

Who are you?*
The patientThe patient's representative

I understand the electronic prescription service and want to register to use it. I agree to nominate Click 2 Pharmacy to collect my prescriptions either via EPS or directly from my GP. I agree that by proceeding, I permit information about my repeat medicines to be sent between my doctor and Click 2 Pharmacy. *