Register for NHS Repeat Prescription Delivery Service

First Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

County

Post Code

Home or Mobile Number

Would you like your medication delivered to your home address?

Yes

Address

Address Line 1

City

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

Do you pay for your medication?

Yes

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?

Please enter below all of the medications which you take (Your Medication List)

Do you have any Controlled medications?

Yes

Do you have any Fridge items?

Yes

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

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.

I have read and agree to the Terms and Conditions and Privacy Policy