Heaton Pharmacy

Prescription collection and delivery service

 

To benefit from our free prescription delivery and collection service,
please complete the form below, in block capitals, and hand to a
member of our dedicated healthcare team.

Doctor______________________________________________________
Surgery address______________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

 

I request that a member of Heaton Pharmacy healthcare team to
collect from the above named surgery on my behalf and to make
arrangements for all my future prescriptions to be dispensed in
this manner.  This may include any future enhancements such as
electronic transfer of my prescription and will allow my dispensed
medicines to be either delivered to my home address or allow me
to collect from Heaton Pharmacy.


If I wish to change this arrangement I will inform you and Heaton
Pharmacy accordingly.

 

Signed__________________________________ Date_______________
Title (Mr, Mrs, Miss, Ms, Dr, Other)______________________________
Surname____________________________________________________
Forename_______________________________ Initials_____________
Home Address_______________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Telephone Number___________________________________________
Date of birth (dd/mm/yyyy)____________________________________

Data Protection Act 1988:  Heaton Pharmacy will hold the information provided on this form either electronically
or by other means for administration purposes to enable improvements to the products and services we offer. 
We will not disclose your information to third parties.