Patient Representative Nomination Form

Please complete the below form to nominate us (Andres Pharmacy) to receive your prescriptions from your doctors surgery electronically.

Patients Full Name (required)

Patients Gender

Patients Date of Birth

Patients NHS Number

Patients Local Medimpo Pharmacy

Patients Email Address (required)

Patients Address

Patients Post Code

Patients Telephone Number

Your Details

I am the Parent/Guardian/Carer of the patient named above (required)

Your Full Name (required)

Please Respond To The Following Statements (required)

I have read and understood the information on EPS nomination and I understand what I have to do:

I confirm that that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination:

I hereby nominate the above named Pharmacy, to be my dispensing site for Electronic Prescriptions:

Please enter the characters from the image above (required)

Your Local Pharmacy