Prescription Nomination Form

	Yes	No
Do you want a text alert to be sent to your mobile phone * once your prescription is ready?
I consent to Shantys Pharmacy accessing my medical record, as it is held with the GP, in order to assist with processing my prescriptions and/or when providing clinical services to me.
I consent to Shantys Pharmacy accessing my NHS Summary Care Record (a summarised record of medicines and allergies held by the NHS), in order to assist with processing my prescriptions and/or when providing clinical services to me.
I consent to receiving communications by email from time to time to make me aware of special offers and services available from Shantys Pharmacy.
I consent to receiving communications by text message from time to time to make me aware of special offers and services available at Shantys Pharmacy.

I would like to nominate Shantys Pharmacy to receive electronic and paper prescriptions from the NHS on my behalf:
Signature

Clear
Date

Day Month Year
Date
Please provide your name and state your relationship to the patient if this form is for someone else.

If you are signing for an adult, then they must be incapable of signing for themselves, and as far as possible, you should have obtained their consent to sign on their behalf.
Your Name
Relationship with patient
Should be Empty:

Patient's Details