NHS Nomination Form

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

NHS Number

Date of Birth(Required)

Gender(Required)

Assigned at birth

Telephone Number(Required)

Home Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Delivery address same as home address?(Required)

Delivery Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Patient NHS Exemption Status(Required)

Exemption Certificate Number (if known)

You would have received this through email or in the post.

Exemption Certificate Expiry Date

(if known)

Agreement(Required)

I am the patient named above/carer of the patient named above

I understand the meaning of nomination and how it works

I understand that I am nominating HealthNest Pharmacy to receive my NHS prescriptions, and I give consent to be contacted with updates about my nomination and orders

I understand the pharmacy will sign my prescription based on the exemption I’ve declared

I understand that incorrect exemption status may result in a fine from the NHS and has nothing to do with the pharmacy.

I give consent for HealthNest Pharmacy to access your NHS Summary Care Records if needed

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