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Nominate a pharmacy

Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

We will only use this email address for correspondence in relation to this request and will not sell it onto third parties.

My chosen Pharmacy is: Required

If you do not nominate a pharmacy then we will assign you to the pharmacy nearest to your home address – but this can be changed at any time.

Not sure what your closest pharmacy is?

Use the NHS Find a Pharmacy tool.