Complete this form to sign-up

*Download Form And Fill The Form After Upload This Patient feedback Form

Please complete this form to sign up to our prescription delivery service, ensuring that all the information is entered accurately. By filling in this form you are asking your doctor to send all your electronic prescriptions to our pharmacy. You can change this nomination at any time.

Medical Details

Are you registering for yourself?

Exemption & ID

Are you exempt from prescription payments? Tick "NO" if you pay for your prescriptions or "YES" if you do not.

The NHS regularly carries out counter fraud checks when patients say that they are exempt from prescription charges. The NHS also requires us to ask you for evidence that you are exempt from paying prescription charges for some types of exemption and to notify them if we do not see this evidence. The NHS can fine you if you wrongly claim to be exempt from paying for your prescriptions even if it is a mistake.

Exemption & ID

Before you sign up, please make sure you’re familiar with our Privacy Policy. regarding how we use your data (as per GDPR guidelines). Only sign up if you accept this policy.

I confirm that Finney Pharmacy bears no responsibility for any parcel damaged after delivery due to external factors such as pets and children in the household. I acknowledge that only I, the patient, will open the parcel. I understand that by signing this from I give permission for my prescriptions and information about my repeat medicines to be sent electronically to Finney Pharmacy and my GP. I understand if the patient does not pay NHS prescription charges, they are properly entitled to exemption and that the information provided is accurate. I understand that if there are any changes to my exemption status, I will contact Finney Pharmacy and failure to do this may result in action by the NHS. I understand the services Finney Pharmacy provide and I am registering to use them. I understand EPS nomination process and nominate Finney Pharmacy to collect my prescriptions on my behalf from my GP.

Prescription details

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