NHS Nomination Form

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

Name*

First Last

Email*

NHS Number

Date of Birth*

Gender*

Assigned at birth

Telephone Number*

Home Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Delivery address same as home address?*

Delivery Address*

Street Address Address Line 2 City ZIP / Postal Code Country

NHS Exemption Status*

Exemption Certificate Number

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

Exemption Certificate Expiry Date

Agreement*

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

NHS Nomination Form

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