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 *0102030405060708091011121314151617181920212223242526272829303132010203040506070809101112212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926Email 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