Your Full Name:

Your DOB:

Your Address:

Telephone Number:

Mobile Number:

Name Of Doctor:

Name Of Surgery:

Do you currently pay for your prescription?
—Please choose an option—YesNo

If NO please provide the reason / exemption:

Would you like to sign up for a repeat prescription?
YesNo

*I consent to Swinton Pharmacy sending me text messages and emails on current offers and promotions.
YesNo

I permit Swinton Pharmacy to keep my repeat prescription form, order and collect my prescriptions from the above surgery, either in person or by means of electronic transfer. If I wish to change this current arrangement I will make sure to inform you. I also consent for you to send a copy to my GP if one is requested by them .

Please enter your initials below along with the date. This will be considered as your digital signature.

Please enter your initials:

Please enter date of signature: