McKay-Pharmacy-Nomination

Collection Point Sign Up Form
Please note, this service is only available to those who have already nominated McKay Pharmacy through their GP surgery.

If you have not yet nominated us as your chosen pharmacy, PLEASE CONTACT YOUR SURGERY AND NOMINATE MCKAY PHARMACY TO COLLECT YOUR PRESCRIPTIONS.
Patient's Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Parent/Guardian's name if signing on behalf of a child under 18
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Surgery Name*
Name of GP*
Dr's Name
Nearest McKay Pharmacy

BelfastNewtownardsTemplepatrick
I'd like to nominate Mckay Pharmacy to manage my medication*

Yes
Agreement

By signing, I consent to:
- Mckay Pharmacy collecting prescriptions on my behalf from my GP practice, requesting prescriptions to be ordered from my GP practice on my behalf and receiving information by SMS text

- Engaging with my pharmacist at any other time that they - or my GP - deem appropriate for the benefit of my health & wellbeing (this is recommended at least twice a year.)

- I understand that any information gathered for me to use the Collection Point will be kept confidential and secure. as outlined in GDPR Privacy at www.mckaypharmacy.com/privacy-policy

- I have read and understood all the above information about the Collection Point and an able to make an informed decision about using it to collect my repeat prescriptions.

- I wish to collect my prescriptions (or those of a child under 18 years old under my core) from the Collection Point under the terms and conditions stated
Signed*
Email
example@example.com
Should be Empty:

Collection Point Sign Up Form

Agreement