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Title *

First Name *

Last Name *

Contact Number *

Email Address *

Date of Birth *

NHS Number (optional)

Full Address *

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GP Details *

Collection Method *Collect from PharmacyDelivery

Are you exempt from paying? *YesNo

Proof of Exemption (JPG, PNG, PDF, max size 2MB)

By ticking this box you are consenting to your future prescriptions being sent electronically to Safys Chemist. We will then dispense your prescriptions and deliver them to you. You can change this nomination at any time.

I would like to sign up to the 24-hour Robotic Collection Point (optional)

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