NHS Electronic Prescription Service (EPS).
Patient Nomination Request & Repeat Prescription Collection Service Consent Form.











Please provide your name and address if you are a representative of the patient.



Please kindly read below:

  • Nomination has been explained to me by the staff at the pharmacy.
  • I understand that the EPS is an NHS funded service and the Repeat Prescription Collection Service is a separate service run by this pharmacy.
  • I can confirm that I have made my nomination of my own free will and have not been influenced or given a gift to several particular nominations.
  • I give my consent for the above pharmacy to contact me when my repeat prescription is ready for collection.
  • I give permission for the above pharmacy to hold the information provided on this form.
  • I give permission for this information to be used in an anonymised format for statistical and research purposes.