Prescription services - Consent Form

Nomination Leaflet

If you need a copy of the nomination leaflet which incorporates the consent form then please download here

Download the Nomination Leaflet

 

I am the patient named in this submission. Or I am the carer of the patient named in this form. Nomination has been explained to me and I have also been offered a leaflet that explains nomination.
I would like to nominate SmartCare Pharmacy as my nominated pharmacy for dispensing prescriptions issued by the NHS Electronic Prescription Service until future notice.

Prescription services - Consent Form

Please type in full ie: 12th September 2021
Tick this box to confirm you have given consent to Smart Care being your nominated Pharmacy