By filling in this form you are asking your doctor to send all your electronic prescriptions to Mottingham Pharmacy. You can change this nomination at any time by contacting us or via the NHS app.
Title*
Full Name*
Phone (Home)
Phone (Mobile)*
Email Address*
Date of Birth*
Address Line 1*
Address Line 2
Address Line 3
Postcode*
GP Details*
Are you exempt from paying?* —Please choose an option—YesNo
Upload proof of exemption (jpg, png, pdf)
By ticking this box you are consenting to your future prescriptions being sent electronically to Mottingham Pharmacy. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.*
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