Prescription Collection Service Registration Form

Davidsons Chemist

To Davidsons Chemists
Please collect my repeat prescriptions from my GP’s surgery.  I will advise you if I want to change this arrangement

Surgery Details

My GP is Dr: 
Surgery name:

Personal Details

Title Mr  Mrs Ms  Other:
Name
Date of Birth
House Number
Street
Town
County
Postcode
Telephone Number

 

Do you pay for your prescriptions  Yes No

If you don't, why are you exempt? (please select)

*We will require to see proof of your exemption status

Please select your local Davidsons Pharmacy    (please select)