Nominate your pharmacy

Fill in your details below and choose where you'd like your prescriptions prepared.

Choose a Pharmacy

Patient Details

First Name(Required)

Last Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

NHS Number

Mobile Number(Required)

Email Address(Required)

Address(Required)

Street Address Address Line 2 City County Post Code Country

GP Surgery

GP Surgery Name

Nomination

Gwilym

I would like to nominate Gwilym Pharmacy as my preferred pharmacy for electronic prescriptions.

I would like to change my existing nomination to Gwilym Pharmacy.

I would like to re-register my nomination with Gwilym Pharmacy.

Talybont

I would like to nominate Talybont Pharmacy as my preferred pharmacy for electronic prescriptions.

I would like to change my existing nomination to Talybont Pharmacy.

I would like to re-register my nomination with Talybont Pharmacy.

Consent

Gwilym Pharmacy to be nominated to receive my NHS electronic prescriptions(Required)

I understand that by submitting this form, I am requesting that Gwilym Pharmacy be nominated to receive my NHS electronic prescriptions.

Talybont Pharmacy to be nominated to receive my NHS electronic prescriptions(Required)

I understand that by submitting this form, I am requesting that Talybont Pharmacy be nominated to receive my NHS electronic prescriptions.

Change or cancel my nomination at any time(Required)

I understand that I can change or cancel my nomination at any time.

Information provided is accurate(Required)

I confirm that the information provided is accurate and that I am the patient named above or have authority to act on their behalf.

Representative Details

Answering on behalf of someone else

I am completing this form on behalf of the patient.

Representative Name

Relationship to Patient

Contact Number

Signature

Type Full Name(Required)

Date

DD slash MM slash YYYY

Signature

Communication Preferences

I would like to receive updates about products, promotions, health campaigns and pharmacy services from New Heights Pharmacy

SMS

Telephone

Email

Marketing Consent

I consent to New Heights Pharmacy contacting me about pharmacy products, health services, promotions, special offers and healthcare information.

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