SIGN UP To get your prescriptions sent to us electronically from your GP, simply fill out this form. If you have any questions, please get in touch. First Name *Last Name *Address Line 1 *Address Line 2 Address Line 3 Postcode *Date of Birth *0102030405060708091011121314151617181920212223242526272829303132010203040506070809101112212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Email Phone Number *NHS number (if known) Prescription Exemption *Please choose from the listNot Exempt - Chargeable itemA - is 60 years of age or over or under 16 years oldB - is 16, 17 or 18 and in full time educationD - Maternity Exemption CertificateE - Medical Exemption CertificateF - Prescription Prepayment CertificateG - Prescription Exemption Certificate issues by Ministry or DefenceL - HC2 [Full Help] CertificateH - Income Support or Income-related Employment and Support AllowanceK - Income-based Jobseeker's AllowanceM - Tax Credit Exemption CertificateS - Pension Credit Guarantee Credit [Including Partners]U - Universal Credit and meets the criteria. Find out more at www.nhsbsa.nhs.uk/UCAdditional information NameSubmit