Nominate Hoyland Pharmacy for EPS

Nominate Hoyland Pharmacy

Please complete this form to nominate Hoyland Pharmacy (operated by TW Healthcare Solutions Ltd) as your NHS Electronic Prescription Service (EPS) pharmacy. Your information will only be used to manage your prescriptions and provide pharmacy services.

Title
MrMrsMissMsMxOther

Full name

Phone (home)

Phone (mobile)

Email address

Date of birth

Address line 1

Address line 2

Address line 3

Town / City

Postcode

GP practice name

GP practice town / postcode

NHS number (if known)

Are you exempt from NHS prescription charges?
No – I pay for my prescriptionsYes – age exemptionYes – medical exemptionYes – maternity exemptionYes – pre-payment certificate (PPC)Yes – other exemption

Any additional information for the pharmacist (optional)

[acceptance* eps-consent]
I confirm that I wish to nominate Hoyland Pharmacy as my NHS Electronic Prescription Service (EPS) pharmacy. I understand that my prescriptions will normally be sent electronically to this pharmacy and that the pharmacy team may access relevant NHS records to support my care.
[/acceptance]

[acceptance* privacy-consent]
I have read and understood the Pharmacy Privacy Notice. I consent to my information being processed for the purpose of providing pharmacy services.
[/acceptance]