Prescription collection registration from

Please fill in the relevant details, print off this form and hand it in at your local Dean and Smedley Pharmacy.

Title:

First Name: Surname:

Address :

Post Code: Telephone Number:

Date of Birth: (Optional)

Surgery Name: Your Doctor's Name:

Your Preferred Pharmacy:

Ashby (Owen Jones)
Littleover (Hollybrook)
Horninglow Road
Mackworth
Measham
Stapenhill
Stretton
Swadlincote
Tutbury
Woodville

I hereby authorise Dean & Smedley pharmacy to collect, either in person or by means of electronic transfer, my prescriptions from the selected surgery above on my behalf. I will inform you if I wish to make any changes to this agreement.

Signed: .................................................... Date:..../...../200...

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