Prescription request form

You can apply for a NHS or Private prescription to be dispensed for you by printing out this form .

This information helps us to process your order and contact you in case of any queries with your medication. Please Print out, complete and send to us with your prescription.

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 £7.10 if NHS non exempt prescription .
If a private prescription include the amount quoted by the Pharmacist.

Cheque Account Name

	*Delivery Address (if different from cardholder)**
Street Address
Address (cont.)
City
County
Postal Code
Country

*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

[ Home ] [ NHS Fees ] [ NHS Exemptions ] [ NHS Prescriptions ] [ FAQs ] [ Ordering ][ABOUT US]

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

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

	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

	Total Amount Payable
Number of items x £7.10 if NHS non exempt prescription . If a private prescription include the amount quoted by the Pharmacist.
Cheque Account Name

Prescription request form

Copyright © 2005[Dispense4me Ltd]. All rights reserved. Revised: April 22, 2008

Copyright © 2005[Dispense4me Ltd]. All rights reserved.
Revised: April 22, 2008