Prescription Nomination Form

Name*

First NameLast Name

Date of Birth*

DayMonthYear

NHS Number*

Address*

Post Code*

Mobile number *

Home Phone Number

Email address*

Consent Section*

	Yes	No
Do you want a text alert to be sent to your mobile phone * once your prescription is ready?
I consent to Lobley Hill 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 Lobley Hill 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 Lobley Hill Pharmacy.
I consent to receiving communications by text message from time to time to make me aware of special offers and services available at Lobley Hill Pharmacy.

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

Signature*

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