Registration Form

First Name *

Last name

Date of Birth *

Address *

Mobile Phone Number *

Email *

GP Surgery Name

GP Surgery Address

Password *

Consent *I agree to the privacy policy.

Final Declarations *I confirm that the information I provide during my consultation(s) will be true and complete to the best of my knowledge.I understand that the pharmacist or prescriber may contact me for more information before supplying any medicines.I consent to my information being shared with my GP or another healthcare professional, when clinically necessary, for the purpose of ensuring safe and appropriate treatment.I understand that if I withhold consent to contact my GP, the pharmacist or prescriber may not be able to supply the medicine I request.I understand that I must not attempt to order medicines for anyone other than myself unless legally authorised to do so (e.g. a parent or legal guardian).I confirm that I am at least 18 years old and legally entitled to request pharmacy services online.I accept the website’s Terms of Use and understand that some medicines may not be supplied without a pharmacist or prescriber’s approval.I agree to be contacted by secure email or telephone if there are any concerns about my medicine request or health information.