Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

We will only use this email address for correspondence in relation to this request and will not sell it onto third parties.

I would like to have my prescription sent electronically.

Other

Not sure what your closest pharmacy is?

Use the NHS Find a Pharmacy tool.