To nominate this pharmacy for your Electronic Prescription Service, please check on the button at the bottom of the page
Patient Date of Birth
Patient GP Practice
NHS Number (optional)
Address Line 1
Street Address Line 2
Address Line 2
Town / City
Postal / Zip Code
I am nominating for
Myself (I am the patient)
Someone Else (I am not the patient)
Representative Phone No.
Representatives relation to Patient
I am the patient named above/carer of the patient named above. Nomination has been explained to me and I have also been offered a leaflet that explains nomination. Also available to download/print here: www.hscic.gov.uk/epspatients
I would like to nominate the Pharmacy named below as my nominated pharmacy for dispensing prescriptions issued by the NHS Electronic Prescription Service.
I confirm that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination and that I can change my mind at a later date.
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