Join Our Free Prescription Service
Use this form to join Harry's Pharmacy Prescription service. Once complete you are then able top place an order immediately or comeback later. Allow at least 7 working days for us to ready any prescription orders.
I am the...
*
Patient
Patients Representative
REPRESENTATIVES DETAILS
First Name
*
Last Name
*
First line of address
*
Second line of address
*
City
*
Postcode
*
Email
*
Phone Number
*
What is your relation to the patient?
*
Please Select
Professional/Registered Carer
Family
Friend/Neighbour
Other
Please state
*
Back
Continue
PATIENTS DETAILS
First Name
*
Last Name
*
First line of address
*
Second line of address
*
City
*
Postcode
*
Email
*
Phone Number
*
NHS Number (optional)
Does patient pay for prescription?
*
Please Select
Yes
No
I don't know
Select exemption / pre-payment method
*
Please Select
B - is 16, 17 or 18 and in full-time education
D - has a valid maternity exemption certificate
E - has a valid medical exemption certificate
F - has a valid prescription pre-payment certificate
G - has a valid War Pension exemption certificate
H - gets, or has a partner who gets Income Support or income-related Allowance
K - gets, or has a partner who gets Income-based Jobseeker's Allowance
L - is named on a current NHS HC2 charges certificate
M - is entitled to, or named on a NHS Tax Credit Exemption Certificate
S - has a partner who gets Pension Credit guarantee credit (PCGC)
Gets Universal Credit and meets the necessary criteria
Don't know
Back
Continue
PRESCRIPTION ORDERING
Do you wish to order repeat medicines now?
Yes
No
Add any items you wish to order here, one item per line. You can include any additional comments.
Would you like us to deliver this your medicines
Please Select
Yes
No
Message (optional)
Back
Continue
NOMINATE HARRYS PHARMACY
Please agree to the following in order to submit the form
*
I understand the prescription service and would like to nominate Harrys Pharmacy to collect prescriptions on behalf of the patient named above
I give permission for information about my repeat medication to be sent between my doctor and Harrys Pharmacy
I give permission for Harrys Pharmacy to access. my Summary Care Record to enable them to provide me with appropriate care.
I have read and understood Harrys pharmacy privacy policy.
Please verify that you are human
*
SUBMIT
Should be Empty: