Electronic Prescriptions Registration

You have chosen to nominate:

Send your EPS Nomination to Brockworth Pharmacy by completing the form below. * indicates a required field.

Tell us about you:

Title

First Name*

Last Name*

Address 1*

Address 2

Town/City

County

Postcode*

Telephone*

Mobile

Email Address*

Confirm Email*

Additional Information:

To help us set your EPS Nomination we require the following information to locate your nomination record on the NHS database.

Date of Birth*

NHS Number

Gender*

Declaration:

Nomination has been explained to me by staff at my GP practice/ community pharmacy/ appliance contractor. I have retained the leaflet providing an overview of EPS and ‘nomination’ and I understand what I have to do.
I understand that EPS is an NHS-funded service and the Repeat Prescription Collection Service is a separate service run by the pharmacy.
I confirm 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.

I confirm the above statements are correct*

I am the patient’s parent / guardian / representative

Signed by name*

Date*