PATIENT REGISTRATION | Pharmacy Bond

REGISTER AS A NEW PATIENT

Please ensure that your credentials are spelt exactly as held with your GP- this includes any middles names you may have (this is not necessary if you provide your NHS number).

First name

Last name

Birthday

Day

Month

Year

NHS number (must be 10 digits)

Email (must include if you want to receive delivery notifications)

Phone

Address

If completing on behalf of the patient please insert your FULL NAME (otherise write N/A)

What is your relationship to the patient (if completing on behalf of the patient)

If you are acting on behalf of the patient and have a power of attorney please upload a copy

When do you next need your medications ? (please err on the side of caution )

Management of medication ordering

I will manage the ordering of my own medications and will notify you when I have ordered my medications so you can look out for it

I want you to manage my medications for me (please note we will only automatically order your regular fixed dose medications)

We are only able to manage the ordering of medications for the surgeries listed above and this is subject to change. We will notify of any future changes

Signature

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You are signing to acknowledge that:

The patient will be nominated to Pharmacy Bond Ltd. This means all electronic scripts will automatically be sent to Pharmacy Bond by your GP
You give permission to Pharmacy Bond Staff to handle your data in line with NHS guidelines and GDPR.

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NEW PATIENT REGISTRATION
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