ETP Nomination Form
Personal details:
Full name:
Full address:
Telephone:
Mobile:
Email:
Surgery information:
Doctor's name:
Surgery name:
Surgery address:
I would like Curie Chemist to keep my repeat slip to order my medication on contact from myself or representative and collect either in person or by means of electronic transfer my prescription from my surgery. I will inform Curie Chemist if I wish to make changes to this arrangement.
I would like Curie Chemist to collect, either in person or by means of electronic transfer, my prescription from my surgery. I will inform Curie Chemist if I wish to make changes to this arrangement.
Are you the patient or the patient’s representative providing these consents?
Patient
Representative (please note that by ticking this box you confirm that you are authorised to act on behalf of the patient and to give consent to the use of information as described in this form)
Representative's full name:
Relationship to patient:
(Click here to Download the ETP Nomination Form in PDF format)