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

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Part Two:
Receiving your prescription

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

Part Three:
Current services

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Part Four:
Payment & Exemption

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Part Five:
Register to use this service

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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]