Nominated Pharmacy

1
Your prescriptions will be sent to your nominated pharmacy electronically. You will not need to collect a paper prescription. If you move, or change pharmacies, you will need to update this form.
2
Name* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.
4
Please choose a pharmacy* This field is required.
Superdrug Harborne
Boots Harborne
Jhoots Harborne
Should be Empty: