Private Prescription Price Enquiry Form
Your information is processed securely in line with NHS‑GDPR standards.
Name
*
First Name
Last Name
Mobile Phone Number we will respond via WhatsApp Messenger
*
Please enter a valid phone number.
Format: 00000-000000.
I can/cannot fully read the prescription
*
Please Select
Yes, I am able to fully read and understand the prescription and requirement
No, I need help deciphering the prescription
Drug or Medicine Name
*
Strength as mg, mcg, mg/5ml (exactly as shown on the prescription)
*
Form of Medicine (capsules, tablets, not specificed, oral solution, ointment etc)
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Quantity Required, or Dosage and Duration of Treatment
*
I understand that
The price quoted is subject to change, and our stock holding is correct at response- we do not reserve any stock unless and until payment is received.
I consent to Beckenham Pharmacy processing my information in accordance with NHS‑GDPR standards.
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I consent to Beckenham Pharmacy processing my information in accordance with NHS‑GDPR standards.
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