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NHS Prescriptions

Register for NHS Repeat Prescription Delivery Service

25%

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
- No
Do you pay for your medication?*
- Yes
- No
Select exemption/Prepayment method*
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*
- Patient
- Patient representative
Untitled*
- 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.

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