Sign-Up For Prescriptions - Your Online Pharmacy

Prescription Sign-Up Form

EPS Nomination Form

Complete this form to sign-up

To nominate us, please complete the form below, or contact us by telephone. Once nominated, your NHS prescriptions will be sent to us. Once checked and prepared your prescriptions, will be delivered to you free of charge via our delivery driver or sent to you in the post.

First Name

Surname

Date of Birth

Address

City/Town

County

Post Code

NHS Number

Telephone

If you are submitting this on behalf of another patient, please state the name below:

Name

By ticking this box you are consenting to your future prescriptions being sent electronically to Remedium Pharmacy. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.

You have the right to receive medicines that have been prescribed for you from any pharmacy you choose.

Your choice should not be influenced by letters you receive in the post, or by any doctor or pharmacist.

Please contact NHS England if someone is trying to influence your decision on which pharmacy you would like to use.

You can contact NHS England in the following ways:

Call: 0300 311 22 33

Email: england.contactus@nhs.net

(with ‘your prescription: your choice’ in the subject line)

Remedium Pharmacy is an independent pharmacy based in Dereham. We aim to provide a speedy, safe and reliable dispensing service to our patients, both locally and nationally.

EPS Nomination Form

Complete this form to sign-up

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