Full Name *

Postal code *

Phone *

Email *

Date of birth *

NHS Number

My Doctors' Surgery *

I would like to collect my prescriptions from: *

Please provide your name and address below if you are a nominated representative of the patient:

Terms & Conditions and Consent

By submitting this form, I confirm that:

I agree to the Terms & Conditions and Privacy Policy of The Health Dispensary.
I consent to the use of my personal information for the purpose of receiving healthcare services, in accordance with UK GDPR and NHS Wales guidelines.
I give consent for The Health Dispensary to be nominated as my preferred pharmacy for electronic prescriptions under the NHS Wales Electronic Prescription Service (EPS).
I authorise The Health Dispensary to receive and dispense my NHS prescriptions electronically, and to contact me with information relevant to my prescriptions, important service updates, or messages from my GP or healthcare team that relate to my ongoing treatment and care.