CUSTOMER INFORMATION

Date of Birth *

DOCTOR'S INFORMATION

Payment and exemption

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

MY AUTHORISATION AND CONSENT

• I understand that my registration with you is subject to Joydens Wood Pharmacy standard terms which i can view at www.jwpharmacy.co.uk

• 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 consent to my prescription:

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• 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​

Thanks for submitting!