Registration for
Prescription Locker

PLease complete
the form:

Register today using the simple form below, making sure to let us know which Prescription Locker you would prefer to collection your completed prescriptions from.

Your name
First Last
Your date of birth(Required)
DD slash MM slash YYYY
Your mobile phone number(Required)
We need a mobile number to be able to send you updates of when your prescriptions are ready to collect.
Your e-mail address(Required)
Your address(Required)
Street Address Address Line 2 City Postcode
Your location(Required)
Your GP's name(Required)
First Last
Authorisation(Required)
Please tick all of the following if you agree and wish to use our 24 hour collection machine. If you do not tick all of the checkboxes you registration may not be valid.
- Select All
- I wish to use the 24 hour collection machine
- I am the patient named above / carer of the patient named above
- I would like to nominate the location I have selected above as my nominated location for collecting NHS prescriptions and the named pharmacy operator to collect prescriptions from my GP practice
- I give permission for my summary care records to be viewed by the named pharmacy operator where appropriate
Comments
This field is for validation purposes and should be left unchanged.

Registration for Prescription Locker

PLease complete the form:

Registration for
Prescription Locker

PLease complete
the form: