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Title
First Name
Last Name
Phone (Home)
Phone (Mobile)
Email Address
Date of Birth
ID Proof (ID passport or Driving license)
House number & street
Apartment, flat etc.
Town / City
County
Postcode
Are you exempt from prescription payments? Tick "NO" if you pay for your prescriptions or "YES" if you do not.
The NHS regularly carries out counter fraud checks when patients say that they are exempt from prescription charges. The NHS also requires us to ask you for evidence that you are exempt from paying prescription charges for some types of exemption and to notify them if we do not see this evidence. The NHS can fine you if you wrongly claim to be exempt from paying for your prescriptions even if it is a mistake.
NoYes
Please upload proof if you have not already done this previously
How many prescriptions do you need to pay for?
Name of surgery
Name of GP
Your pharmacy branch —Please choose an option—Narborough RoadCross StreetWollaton RoadNottingham RoadHartington RoadWelford RoadSpinney HillCoventryBridge Road
Please write down the Name, Strength, Form and Quantity of each medicine you require e.g. Atenelol Tablets 25mg x 28. Only order what you need.
I consent to Vision Pharmacy running an SCR check for a summary on my care records.
No appointment or long waiting times
Plain packaging with no medical stamps or marks
Your information stays with us and private payment
Dispensed by registered UK pharmacists
