Sign up for prescription

Doctor's name

Surgery

Your DOB

Your name

Your Address

Telephone:

Mobile:

Do you pay for your prescription?
---YesNo

If NO then please provide reason / exemption:

Would you like to sign up for repeat prescription?
YesNo

*I give consent to Manchester Pharmacy to send me text messages and emails on pormotions an doffers.
YesNo

I would like to authorise Manchester 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 arrangement I will inform you. I also consent for you to send a copy to my GP if they request it.

Please enter your initial below with date. This will be considered as digital signature.

Please enter your initials below:

Date: