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Worried that you have an it 111.nhs.uk

Registration Form for Free Delivery and Electronic prescription services

CUSTOMER INFORMATION

First Name

Middle Name(s)

Surname

Address Line 1

Address Line 2

Town

Postcode

Gender

Date of Birth

Telephone

Mobile

DOCTOR'S INFORMATION

Surgery Name

Surgery Address Line 1

Surgery Address Line 2

Surgery Town

Surgery Postcode

Payment and exemption

I pay for prescription charges.

If you do not pay prescription charges please tell us why (tick the relevant option below).

I am under 16 years of age

I am a full time student aged 16-18

I am 60 years of age or over

I have a valid maternity exemption certificate

I have a valid medical exemption certificate

I have a valid prescription pre-payment certificate

I have a valid war pension certificate

I am named on a current H 2 Charges certificate

I am prescribed free of charge contraceptives

I receive income support

I receive income based job seekers allowance or universal credit

I am entitled too or named on, a valid NHS tax credit exemption certificate

I have pension Credit (Guarantee Credit) paid on it's own or Pension Credit (Guarantee Credit with Savings Credit)

I have a partner who gets pension credit (guarantee credit)

MY AUTHORISATION AND CONSENT

I understand that my registration with you is subject to Joydens Wood Pharmacy standard terms which i can view at
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 01322 522 711.
I understand that if i do not, you may take appropriate action.

I agree

I consent to my prescription:

being collected from my GP Surgery
being from my GP Surgery using the Electronic Prescription Service (EPS) to Joydens Wood Pharmacy
being to delivered to the address stated on this form
my contact details being used for communication purposes only in relation to matters concerning prescripition collection or delivery

I agree

Thanks for submitting!

Contact

2 Birchwood Parade, Woodside Drive, Wilmington
Kent
DA2 7NJ

01322 522 711

Information

Premises GPhC Number:
1032690

Superintendent Pharmacist
Jasminder Wasu (2030585)

Worried that you have an urgent medical condition call 111 or visit 111.nhs.uk

Opening Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

09:00 to 13:00
14:00 to 18:30

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09:00 to 13:00
14:00 to 18:30

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09:00 to 13:00
14:00 to 18:30

09:00 to 13:00
14:00 to 18:30
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09:00 to 13:00

14:00 to 18:30

09:00 to 13:00
14:00 to 16:00

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