Wicker 2 U

Remind me to order my meds: phone, text or e- mail me every four weeks to remind me to check if I require repeat items and that I need to re-order these from my surgery.
Order my meds: order my repeat prescriptions on my behalf from my surgery. (only available if surgery accepts pharmacy ordering)
Remind me to collect my meds: Please let me know when my items are ready to be collected from Wicker Pharmacy: (please tick one)

Deliver my medication to my home or place of work or other chosen address within Sheffield. I understand this is a service I have to pay for if my repeat prescriptions are less than 5 items. The charge for this service is £3 per delivery (£6 to non-regular customers). Please note – MoT (Blister Pack) customers receive one free delivery per week.

Name *

Address *

Date of Birth *

Home Tel *

Work Tel *

Mobile *

Email *

Delivery Address: (if different from above)

Doctor *

Surgery *

I pay for my prescription – please sign the declaration.I am exempt from prescription charges – please complete the exemption reason and sign the declaration.

The patient doesn’t have to pay because he/she:
Not applicableA - Is 60 years of age or over or is under 16 years of ageB - Is 16, 17 or 18 and in full-time educationC - Has a valid maternity exemption certificateD - Has a valid medical exemption certificateE - Has a valid prescription pre-payment certificateF - Has a valid exemption certificate issued by Ministry of DefenceG - Is named on a current HC2 (full help) certificateH - Income Support or income-related Employment and Support AllowanceI - Income-based Jobseeker’s AllowanceJ - Tax Credit exemption certificateK - Pension Credit Guarantee Credit (including partners)L - Universal Credit and meets the criteria. Find out more at www.nhsbsa.nhs.uk/UC

I declare that the information given on this form is correct and complete and I confirm the proper entitlement to exemption.
I understand that if I falsely claim, I may be issued a Penalty Charge Notice, and I may have to pay up to £100 – as well as my prescription charge(s).
I understand that the NHS Business Services Authority may use and share my information with the NHS and with relevant government bodies to check for fraud and mistakes. Find out more at: www.nhsbsa.nhs.uk/yourinformation
Signature *

I authorise the staff of Wicker Pharmacy to:

Sign prescription charge exemption forms on my behalf.
Collect (either in person, via the postal service or, where available, electronically) prescriptions from my surgery.

The electronic prescription service is a free confidential, safe, method of prescriptions being electronically delivered from your GP to a pharmacy of your choice, which takes the place of paper prescriptions. In order to do this you need to nominate a pharmacy to receive your electronic prescriptions. If you change your mind you can nominate another pharmacy. Some prescriptions will always still be issued on paper and you can always choose to have a paper prescription if you’d prefer it. (please ask if you require an information leaflet)
I agree to allow Wicker Pharmacy to electronically collect my prescriptions from my surgery and that this means all my electronic prescriptions will automatically be sent to Wicker Pharmacy for collection or delivery.
I understand the above overview of EPS and “nomination”.
I understand that EPS is an NHS-funded service and the Prescription Collection and Delivery Service is a separate service run by the Wicker pharmacy.
I confirm 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.
Should my exempt status change I will inform Wicker Pharmacy of this change and, if necessary, pay the prescription charges required.

The pharmacist or pharmacy technician involved in providing care may need to view your Summary Care Record (this is a list of medications from your GP) in order to provide the best possible care for you and have the most up to date information.
I give permission for the pharmacist or pharmacy technician to access and view my Summary Care Record if needed during the course of my care.
Signature *