Prescription Collection - Community Support
Form to collect details of prescription collections, for those in need
Email address *
Who are you completing this form on behalf of *
If you are completing this form on behalf of Another, you must be a Council officer or working for a recognised support organisation.
First name *
Please enter your First name as held by the Pharmacy.
Your answer
Surname *
Please enter your Surname as held by the Pharmacy.
Your answer
Address *
Please enter the First Line of address, including House name/Number and Street/Road
Your answer
Postcode *
Please enter the Postcode for your address, where you live. We cover ALL OX11 and some OX12, OX13 and OX14 postcodes near Didcot.
Your answer
Telephone Number *
Your telephone, either mobile or landline - no country codes please
Your answer
Please select which Pharmacy does your medication need collecting from *
Which Pharmacy has your Medication, select one listed or input Other... if not listed
NHS Prescription Charges *
If you are not exempt or haven't paid your Pharmacy over the phone, you will need to electronically arrange payment to the person assisting you in advance, via something like PayPal friends and family. They will contact you if you select "Other" to arrange payment of NHS charges.
When does this need collecting? *
If not immediately available and As Soon As Possible, please give a date for collection.
How many packages of medication need collecting?
Your answer
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This form was created inside of Great Western Park Residents' Association. Report Abuse