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NHS Prescription Nomination Form

Please fill in the form below to nominate SimplyMeds Online as the patient’s chosen pharmacy.

This form is for registering a patient for NHS prescription dispensing in England. We are unable to register patients who live in Wales, Scotland or Northern Ireland.

Your details

Title

First Name*

Last Name*

Email*

Date of Birth*

Password*

Confirm Password*

Telephone No*

Please confirm your relationship with the patient*

Patient details

Title

First Name*

Last Name*

Email*

NHS Number*

Date of Birth*

Gender*

Telephone No*

Postcode

Address 1

Address 2

Address 3

City

Country

Password*

Confirm Password*

Exemption Status

THE PATIENT PAYS FOR THEIR PRESCRIPTIONS

is 60 years of age or over or is under 16 years of age (unless your date of birth is printed on the form)

is 16, 17 or 18 and in full time education

Maternity exemption certificate

Medical exemption certificate

Prescription prepayment certificate

HRT only prescription prepayment certificate

Ministry of Defence prescription exemption certificate

HC2 (full help) certificate

Income-related Employment and Support Allowance

Tax Credit exemption certificate

Pension Credit Guarantee Credit (including partners)

Universal Credit and meets the criteria

Exemption Certificate Number

Exemption Certificate Expiry Date

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.

Did you get a referral code? Please enter it here

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