NHS Electronic Prescription Service

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Postcode

Contact No.

Date of birth

NHS No.

I am the patient named above/carer of the patient named above.
Nomination has been explained to me and I have also been offered a leaflet that explains nomination.
I would like to nominate PHARMPLEX DIRECT/GREWAL PHARMACY as my nominated pharmacy for dispensing prescriptions issued by the NHS Electronic Prescription Service.

Signature.

Date