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 Allied Pharmacies 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 0127 088 2049

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Call us on 01744 813306

Allied Pharmacies, Unit 18, Bold Industrial Park Neills Road, St Helens Merseyside, WA9 4TU