First Name (Required)

Last Name (Required)

Date of Birth (Required)

Gender
---Rather Not DiscloseMaleFemale

Your email

Contact Telephone Number

Address 1

Address 2

Town

City

Postcode

NHS Number (If known)

Are you exempt from NHS prescription charges?
---I pay for my prescriptionsOver 60Under 1616,17,18 and in full-time educationPrescription Prepayment CertificateMedical Exemption CertificateMaternity Exemption CertificatePrescription Exemption Issued by the Ministry of DefenseHC2 Full Help CertificateIncome Support / Employment and Support AllowanceIncome Based Job Seekers AllowanceTax Credit Exemption CertificatePension Credit Guarantee CreditUniversal Credit and meets criteria eligibility criteria

Collection or Delivery
---CollectionDelivery

If Collection - would you like a text message when your prescription is ready?
---YesNo to be picked up from our branch: Park View Pharmacy, 125 Fitzwilliam Street, Huddersfield, HD1 5PS

For "Delivery" are there any special notes (e.g Drop at number 42 if not in...etc)

Would you like to sign up to our blister pack service? (Free Service)
For patients who are on 4 or more regular medicines we provide a free blister pack service.
---YesNo

Select Patients GP
---Almondbury SurgeryBirkby Health CentreColne Valley Family DoctorsCroft Medical CentreCrosland Moor SurgeryDalton SurgeryDearne Valley Health CentreElmwood Health CentreFartown Green Road SurgeryFieldhead SurgeryGreenhead Family DoctorsThe Grange Group PracticeHonley SurgeryJunction SurgeryKirkburton Health CentreLepton and Kirkheaton SurgeriesLindley Group PracticeLindley Village SurgeryLockwood SurgeryMarsh SurgeryMeltham Group PracticeMeltham Road SurgeryNew Street & Netherton Group PracticeNewsome SurgeryNook SurgeryOaklands Health CentrePaddock and Longwood Family DoctorsRose Medical PracticeShepley Health CentreSkelmanthorpe Family DoctorsSlaithwaite Health CentreThornton Lodge SurgeryUniversity Health CentreThe Waterloo PracticeWestbourne SurgeryWhitehouse CentreWoodhouse Hill SurgeryOther

For further information on the eligibility criteria for free NHS prescriptions whilst on Universal credit please visit www.nhsbsa.nhs.uk/uc

It is your responsibility to keep us informed of any changes to your NHS exemption status

NHS Electronic Prescription Service (EPS)
I agree to be nominated by Siky ltd so they can process my NHS prescriptions. Siky ltd trade as Park View Pharmacy. Your nominated NHS Pharmacy will show as Park View Pharmacy replacing your current pharmacy you use. If you have further questions about this please give us a call for further information .

I Agree to SCR Access
Summary Care Record (SCR) Pharmacists and Pharmacy Technicians now have the ability to view a summary of your health care records. These records include important information that can help us work safely. This is especially important when we are working at a distance. The SCR includes lists of regular repeat medication and long term conditions these medicines help treat. NHS Digital monitors all access to this data and the information will only be viewed whilst you are under our direct care for the purpose of healthcare. By ticking this box you agree that our team may access your SCR when required.