Registration form for repeat prescriptions

Registration form

To use our services, please complete the registration form below. This allows us to contact your GP.

Name
Date of birth	/ /
Your address
Postcode
Daytime telephone number
Mobile number
Your Email
Doctor's name
Surgery name
Surgery address

I give my consent for Sutton Pharmacy to retain my repeat slip, order my repeat prescription and collect from my GP surgery (either in person or by electronic transfer).
I agree to Sutton Pharmacy contacting myself or my GP’s surgery to verify my required prescription items, or to advise me my repeat prescription is ready for collection.
I give my permission for Sutton Pharmacy to hold the information provided on this form.

Sutton Pharmacy may contact you regarding healthcare services offered by Sutton Pharmacy. Please tick this box if you do not wish to be contacted.

I will contact Sutton Pharmacy if I wish to change this agreement.