Prescription Payment

*Do you pay for your prescriptions upon collection? (please tick)

I currently pay for my prescriptions (do not tick this box if you have a prepayment certificate – see below)

I am currently exempt from prescription charges (NHSBSA may fine you if you falsely claim an exemption)

I am aged 15 years or younger, or 60 years or older

I am 16, 17 or 18 years of age and in full-time education

I hold a maternity exemption certificate

I hold a medical exemption certificate

I hold a prescription prepayment certificate

I hold a HC2 certificate

I receive Income Support or Income-related Employment and Support Allowance

I receive income based job seeker’s allowance

I hold a tax credit exemption certificate

I meet the criteria for free prescriptions under universal credit

My prescription is for contraceptive services only

Declaration

* Please tick this box to confirm your Declaration of full understanding and agreement to the following Points:

1) I consent to text messages regarding collection of medication to be sent to the number stated above.

2) I agree to abide by the codes of conduct.

3) I understand that it is my responsibility to inform the dispensary if any of the above details change.

4) I understand my prescription must be collected within 5 days of being informed my prescription is ready.

5) I understand that controlled drugs and items requiring refrigeration cannot be collected from PharmaSelf24.