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Name
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First Name
Surname
Date-of-Birth
*
Date Format: DD slash MM slash YYYY
Address
*
Street Address
City
Post Code
Phone Number
Would you like your medication delivered to your home address?
*
Yes
No
Address
*
First Line of Address
Post Code
To help with convenience (dependent upon medication type) we may post your items through your letterbox subject to size. I confirm and consent, that it is safe and suitable for Live Well Nationwide to post the medication through the letterbox
Yes
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Do you pay for your medication?
*
Yes
No
Select exemption/Prepayment method
*
Select exemption/Prepayment method
A – is under 16 years of age OR is 60 years of age or over
B – is 16,17 or 18 and in full-time education
D – has a valid maternity exemption certificate
E – has a valid medical exemption certificate
F – has a valid prescription pre-payment certificate
G – Prescription Exemption Certificate issued by the Ministry of Defence
H – gets, or has a partner who gets Income Support or income related allowance
K – gets, or has a partner who gets Income based Jobseekers's Allowance
L – is named on a current NHS HC2 charges certificate
M – is entitled to, or named on a NHS Tax Credit Exemption Certificate
S – has a partner who gets Pension Credit guarantee credit (PCGC)
U – Gets Universal Credit and meets the necessary criteria
If you would like us to order medication for you or send you reminders please provide us the date you will next run out?
MM
DD
YYYY
* Depending upon your surgery as some do not allow pharmacies to order medication on your behalf
Please enter below all of the medications which you take (Your Medication List)
*
If you can’t remember the names please write how many different medicines you take
Do you any Fridge items?
*
Yes
No
Do you have any Controlled medications?
Yes
No
I declare that IF the patient does not have to pay NHS prescription charges, they are properly entitled to exemption and that the information is true and complete. I also declare that if the entitlement changes, I will tell Live Well Nationwide immediately on 01782 310001, and I understand that if I do not do so, appropriate action may be taken by the NHS. I understand the services you provide and want to register to use them. I understand EPS nomination and nominate you to collect my prescriptions on my behalf either via EPS or direct from my GP. I understand that by signing this from I give permission for my prescriptions and information about my repeat medicines to be sent electronically between my doctor and Live Well Nationwide
*
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By ordering medication from Live Well Nationwide and providing us with your delivery address you confirm that you have appropriately risk assessed your shipping address for:
– Security of the parcel
-NO CHILDREN or PETS have access to the parcel
– The parcel will ONLY be opened by the Name individual
-if receiving Temperature controlled or Controlled Medication you will be in to receive delivery – as signature will be required.
