Prescription request form          

                                         Patients Details  

Patient Name
Title
Street Address
Address (cont.)
City
County
Postal Code
Sex	Male  Female

          Date of Birth             email address    

                                        Phone No

            Please provide Doctors Name, Address & Postcode:

Name
Title
Street Address
Address (cont.)
City
County
Postal Code
Country
Surgery Phone No

          Delivery & Payment Instructions: Your card will only be charged at time of dispatch

	BILLING
Credit Card
Cardholder Name
Card Number
Expiration Date

	CARD HOLDERS ADDRESS (if different from patient)
Street Address
Address (cont.)
City
County
Postal Code
Country

              If paying by Cheque please make payable to Dispense4me Ltd and add your 

              address and  card  number  on the reverse :                                                              

	Total Amount  Payable
Number of items x £7.20 if NHS non exempt prescription . If a private prescription include the amount quoted by the Pharmacist.
Cheque  Account Name

     *If your place of work please ensure that the postal reception process is secure and that someone approved   by  you is able to sign for the delivery.

                        Optional Information

                Please enter Medical Conditions, Drug Allergies, Counter Medicines taken etc in the box below

Please tick relevant box if any of the following apply

Pregnancy                   Breastfeeding               Difficulty opening child resistant tops

I confirm the above information is correct:               

SignatureDate

Please send this form with your signed and completed  prescription to:-Dispense4me Ltd, 14-20 Field Street,Shepshed,Leics,LE12 9AL.Remember to enclose your Cheque (made payable to Dispense4me Ltd)  if not paying by card. If exempt from NHS prescription charges please photocopy your proof of exemption and include with your order.  Delivery usually is 5 working days from posting your prescription