EPS Nomination - Patients | Rudgwick Pharmacy

Please complete the below form to nominate us (Rudgwick Pharmacy) to receive your prescriptions from your doctors surgery electronically.

Patients' Full Name
Patients' Gender
MaleFemaleIntermedidate
Patients Date of birth mm/dd/yyyy
Patients' NHS Number If you have it - This can be found on the top right hand corner of your prescriptions
Patents' E-mail Address: *
Patients' Address
Patients' Postcode
Patients' Telephone Number No Spaces

I have read and understood the information on EPS nomination and I understand what I have to do: *
Agree
I confirm that that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination: *
Agree
I hereby nominate the above named Pharmacy, to be my dispensing site for Electronic Prescriptions: *
Agree

Rudgwick Pharmacy