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First Name *

Last Name *

D.O.B *

Do you pay for prescriptions? *

Exemption reason *

Email *

Mobile

GP surgery *

GP surgery postcode

How did you find us?0 characters / 0 words

Password *

Password Confirmation *

Billing First Name

Billing Last Name

Billing Company

Billing Address 1

Billing Address 2

Billing City

Billing State

Billing Postal/Zip Code

Billing Country or Region

Billing Phone Number

Billing Email Address

Shipping First Name

Shipping Last Name

Shipping Company

Shipping Address 1

Shipping Address 2

Shipping City

Shipping State

Shipping Postal/Zip Code

Shipping Country or Region

By submitting this form you will a) register to use our website and b) nominate Patient Choice as your preferred contractor to dispense NHS prescriptions for home delivery.

I nominate Patient Choice as my preferred NHS dispensing appliance contractor and have read and understood the nomination terms. I understand that Patient Choice may use my information in the provision of their services and to keep me informed about their services. *

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