ETP Nomination Form Personal details: Full name: Full address: Telephone: Mobile: Email: Surgery information: Doctor's name: Surgery name: Surgery address:     I authorise Bees Dispensing Chemist to order my medication on contact from myself or my representative and collect my prescription from my surgery. I will inform the Pharmacy if I wish to make changes to this arrangement.     I would like Bees Dispensing Chemist to keep my repeat slip to order my medication automatically at the required interval and collect my prescription from my surgery. I will inform the Pharmacy if I wish to make changes to this arrangement.     I would like Bees Dispensing Chemist to collect, either in person or by means of electronic transfer, my prescription from my surgery. I will inform Bees Dispensing Chemist if I wish to make changes to this arrangement.     Are you the patient or the patient’s representative providing these consents? Patient Representative (please note that by ticking this box you confirm that you are authorised to act on behalf of the patient and to give consent to the use of information as described in this form)     Representative's full name: Relationship to patient: Download the ETP Nomination Form (PDF format)