SKIPTON REGISTRATION FORM

Registration Form

Name: Enter Name

Required

Email: Enter Email

Required

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Form received.

Home Address: Enter Address

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City: Enter City

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Postcode: Enter Postcode

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Mobile Phone: Enter Phone Number

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DOB: dd/mm/year

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Surgery Name: Enter Surgery Name

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Surgery Address: Enter Surgery Address

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Surgery Postcode: Enter Surgery Postcode

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Paid for NHS Prescriptions:

I am a paying patient

I am NOT a paying patient

Signature: Enter Signature

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Date: Enter Date

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*If any of your details change, please contact Olive Pharmacy immediately.

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.

Paid for NHS Prescriptions

Application to take part in this service

We respect your privacy. We will use your personal information in line with our privacy policy at www.olivepharmacy.co.uk.

We will not sell your information to anyone, for any reason.

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