Register for prescriptions

Complete the form below to nominate Gibbs & Gurnell Pharmacy for your NHS electronic prescriptions. You can change your nomination at any time by letting us know personally.

First Name

Surname

Date of Birth

NHS Number

Phone Number

Address

Additional Requirements or Requests

I agree to receive marketing communication

I consent to this pharmacy managing my prescription nomination for six months from the date of signing and understand that I may change my nomination at any time.

Exemption

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 Gibbs & Gurnell 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

Signature

Date