24 hour Medicines Collection Machine Sign Up First Name Surname Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Mobile Telephone NumberIf 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 Name OptionalThis field is for validation purposes and should be left unchanged.