Part One:
Your details - as registered at your local GP


Part Two:
Receiving your prescription


Please specify below whether you require delivery or wish to collect your prescription:

If you have selected delivery, please enter your delivery address below. If you plan to collect your medication please skip to section three.

Your prescriptions will be ready to collect from your nomitated pharmacy in Part Three of this form.

Part Three:
Current services


Part Four:
Payment & Exemption


Part Five:
Register to use this service


I am the patient/patient's representative and would like to register to use the selected pharmacy in this form for the NHS Prescription Service, I understand EPS nomination and nominate Ascent Pharmacy to dispense my prescriptions. By signing this form, I give permission for information about my repeat medicines to be sent between my doctor and the selected pharmacy.

If I have stated I am exempt from payment, I confirm I am properly entitled to exemption and that if my entitlement changes, I will tell you immediately on [phone number]

Call us on 01332 429390

enquiries@ascenthealthcare.co.uk

9 Riverside Court ,1st Floor Pride Park, Derby DE24 8JN