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

Other