.::Green Lanes Pharmacy::.

ETP Nomination Form

Personal details:
*Full name:
*Full address:
*Date of Birth:
NHS Number:
Telephone:
Mobile:
Email:
Surgery information:
*Doctor's name:
*Surgery name:
*Surgery address:

*Please indicate your Nomination
I authorise Green Lanes Pharmacy 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 Green Lanes Pharmacy 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 Green Lanes Pharmacy to collect, either in person or by means of electronic transfer, my prescription from my surgery. I will inform Green Lanes Pharmacy 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)