Prefix
MrMissMrsMsDrSir

First Name

Last Name

Date of Birth

Your email

Mobile Number

Phone Number

Gender
MaleFemaleOther

NHS Number (if Known)

Address

Name of Surgery

Type of medicines

Prescription payment / exemption status
PayingExempt

If you do not have to pay, please select one of the follow exemption type:
A. is 60 years of age or over or is under 16 years of ageB. is 16, 17 or 18 and in full time educationD. Maternity exemption certificateE. Medical exemption certificateF. Prescription prepayment Certificate (PPC)W. HRT only prescription prepayment certificateG. Prescription exemption certificate issued by Ministry of DefenceL. HC2 (full help) certificateH. Income Support (IS) or Income-related Employment and Support Allowance (ESA)K. Income-based Jobseeker’s Allowance (JSA)M. Tax Credit exemption certificateS. Pension Credit Guarantee Credit (including partners)U. Universal Credit and meets the criteria

Exemption certificate number (if applicable)

Exemption certificate expiry date (if applicable)