24 hour Medicines Collection Machine Sign Up

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First Name

Surname

Date of Birth

Address

Street Address Address Line 2 City Postcode

Mobile Telephone Number

If you do not pay for your prescriptions, please specify your exemption here: Optional

Patient declaration:

I would like to sign up to use the 24-hour prescription collection service.

I accept that it is my responsibility to inform the surgery of any change to my mobile number.

I am aware that I need to collect my prescription within 3 days of receiving my collection code.

I understand that some orders may not be suitable for collection from the machine