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NHS
NHS Prescriptions Sign up Form
Please fill in the form below to nominate Simply Prescriptions as your pharmacy
Title
Mr
Mrs
Ms
Miss
Prof
Dr
First Name*
Last Name*
Email*
NHS Number*
Date of Birth*
Gender*
Select
Female
Male
Telephone No*
Postcode
Password*
Confirm Password*
Full Address
Exemption Status
THE PATIENT PAYS FOR THEIR PRESCRIPTIONS
60 years old or over
Under 16 years old
Aged 16 to 18 and in full-time education
Have a Valid Maternity Exemption Certificate
Have a valid Medical Exemption Certificate
Are named on a valid war pension exemption certificate
Get Income Support
Get Income-based Jobseeker Allowance
Get Income-related Employment and Support Allowance
Get Pension Credit Guarantee Credit
Receive Universal Credit and meet the criteria
Are named on a valid NHS tax credit exemption certificate
Are named on a valid NHS HC2 Certificate
Agreement
I am the patient named above/carer of the patient named above
I understand that I am nominating Simply Prescriptions to receive my NHS prescriptions via the Electronic Prescriptions service for dispensing.
I understand the meaning of nomination and how it works.
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