EPS Nomination Form

Full Name*

Phone Number*

Email Address*

Date of Birth*

Address Line 1*

Address Line 2

Address Line 3

Postcode*

GP Details*

Are you exempt from paying?*
YesNo

Collection
We offer collect in pharmacy only
Collect in pharmacy

By ticking this box you are consenting to your future prescriptions being sent electronically to Carrington Pharmacy. We will then dispense your prescriptions and can collect at the pharmacy. You can change this nomination at any time.

I accept