NHS Electronic Prescription Service

NHS Electronic Prescription Service (EPS) Patient Nomination Request and Repeat Prescription Service Consent Form

Full Name: *
Date of Birth: *
Gender: select male female
Address: *
Postcode: *
Tel: *
Email: * *
NHS Number (top right on prescription):

Please provide your name and address if you are a representative of the patient.

Full Name:
Address:
Postcode:
Tel:

I understand that EPS is an NHS funded service and the Repeat Prescription Service is a separate service run by this pharmacy.

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.

I give my consent for my nominated pharmacy to retain my repeat prescription request slip and for them to verify items with me prior to re-ordering from my GP surgery

I give my consent for my nominated pharmacy to contact me when my repeat prescription is ready for collection.

I give my permission for my nominated pharmacy to hold the information provided on this form.

I am the patient's representative
Prescription preference: select post collect

Name: *

Electronic Signature: select yes agree