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EPS PHARMACY NOMINATION

Please complete all questions below.

Your Details

Full Name: Date of Birth: Home Post Code: Telephone Number: Nominated Pharmacy: Other Pharmacy:

Confirm your Location

I confirm that I am a patient at Grove House Surgery, Shepton Mallet, Somerset.

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

Submit your Request

By submitting this nomination form you are choosing a pharmacy in which you would like all your prescriptions to be sent electronically to as a default. You can change your nominated pharmacy at any time by resubmitting an online form or writing to us. For your information the EPS system does not currently allow controlled drugs to be sent electronically and so these will need to be processed in the normal paper prescription way.

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