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  • Prescription Nomination Form

  • Patient's Details

  • Consent Section

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

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  • 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.

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