Patient Nomination Form

The Electronic Prescription Service (EPS) is an NHS service that allows your doctor surgery to send your prescription(s) directly to your nominated pharmacy electronically. This means that you no longer need to visit your doctor surgery to pick up your prescription(s) and drop it off at the pharmacy.

First Name *

Last Name *

DOB (DD/MM/YYYY) *

Address *

Postcode *

Phone Number *

GP Surgery *

Are you on Repeat Medication?

I give Brinsley Pharmacy my consent to view my summary care records that are held on the NHS cloud for clinical checks.