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Date of Birth*
House number & street*
Apartment, flat etc.*
Town / City*
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.
Please upload proof if you have not already done this previously
How many prescriptions do you need to pay for?
Name of surgery
Name of GP
Please write down the Name, Strength and Quantity of each medicine you require e.g. Atenelol Tablets 25mg x 28. Only order what you need.*
Please sign here*