INGROW ORDER MEDICATION FORM

Patient Details

Name: Enter Name

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Email: Enter Email

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Message: Enter Your Message

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Mobile Phone: Enter Phone Number

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Home Address: Enter Address

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City: Enter City

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Postcode: Enter Postcode

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Surgery Name: Enter Surgery Name

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Surgery Address: Enter Text

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Surgery Postcode: Enter Text

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Patients for their representatives who do not have to pay for the NHS Prescriptions must fill in the section.The patient is exempt because he or she:

is 60 years of age or over

is under 16 years of age

is 16, 17 or 18 and in full time education

has maternity exemption certificate

has a medical exemption certificate

has a prescription prepayment certificate

has a war pension exemption certificate

is named on a current HC2 charges certificate

gets Income Support or income-related Employmentand Support Allowance

gets income-based jobseeker's allowance [JSA(IB)]

is entitled to, or named on a valid NHS Tax Credit Certificate

has a partner who gets Minimum Income Guarantee (MIG)

has a partner who gets Pension Credit Guarantee Credit (PCGC)

Paying for NHS Prescription:

Pay on delivery

Pay prior to delivery

Date: Enter Date

Required

Exemption from NHS Prescriptions

If stated exempt from payment, I declare that the patient does not have to pay NHS prescription charges, is properly entitled to

exemption and that the information is true and complete. I further declare that should the entitlement change, I will inform Olive Pharmacy immediately, and I understand that if I do not do so appropriate action may be taken.

WARNING! False information may lead to legal action.

I give my permission to Olive Pharmacy to order and receive prescriptions (paper or electronic) from my doctor's surgery and to verify my required prescription items. I will contact Olive Pharmacy if you want any arrangement changed. I give permission to Olive Pharmacy to hold the information provided in this form.