Comments and Suggestions Form


Do not use this form for Medical matters or Complaints.

IF YOU WOULD LIKE TO USE THIS FORM TO SIGN UP FOR THE NHS ELECTRONIC PRESCRIPTION SERVICE (EPS) PLEASE:

Choose Other as the type of comment.
Copy and paste the wording below into the Comments Box.
Make sure to add the name and address of your nominated pharmacy. You can find a pharmacy near you at www.nhs.uk/Service-Search/Pharmacy/LocationSearch/10?nobeta=true.
Please also tell your pharmacy to expect your prescriptions electronically.

* I want to Opt-in to the NHS Electronic Prescription Service (EPS).
*I have read the Patient Information Leaflet about EPS.
* I understand I can Opt-out of EPS or change my pharmacy at any time
* I want to Nominate the following pharmacy to receive my prescriptions electronically
*Name of pharmacy:
*Address / Branch of pharmacy:
What kind of comment would you like to send? Remember this form is not for medical matters.
     
What would you like to say?

Your contact details
Do you agree to be contacted regarding this matter?

About This Form

Note that by using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your comment.

Your IP address () will be sent with your communication. In rare cases where abuse or criminal activity can be shown to have taken place this may be used by the authorities to trace you.