NHS Electronic Prescription Service

Patient Full Name *

Patient Address inc Postcode*

Telephone Number *

Email (required)

Date of birth *

NHS Number

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.

I would like to nominate Pharmalogic Chemist as my nominated pharmacy for dispensing prescriptions issued by the NHS Electronic Prescription Service.

Choose an option from below:

I would like Pharmalogic to deliver my medication for FREEI will collect my medication from the pharmacy

Please sign below: *

Date *